*AGREEMENT AND ASSUMPTION OF RISK

I understand and agree that in participating in any movement/dance class, workshop, or program with “The Moving Self Therapy”, whether my participation is in-person or virtually, there is a possibility of accident, injury and/or illness. In addition, programs may bring up emotions and discuss topics that are personal. I voluntarily agree to assume all risks and responsibility for any such injury, accident or illness, which might occur to me during any “The Moving Self Therapy” classes, workshops, or programs. I also exempt, release, and indemnify “The Moving Self Therapy”, its owners, agents, volunteers, assistants, contractors, partners, and/or students from any and all liability claims, demands, or causes of action whatsoever from any damage, loss, injury, illness, or death to me, or my property which may arise out of or in connection with participation in any activities conducted by “The Moving Self Therapy”. I understand that I am expected to be aware of my own physical and emotional limitations, and agree not to exceed them. I understand that it is my responsibility to make the program leader(s)/facilitator(s) aware of any medical condition or physical limitations I have before participation. (If I am the guardian of this participant, I certify that I have the right to agree to this statement on behalf of the participant).

By clicking below, I agree to be bound by the above terms

I agree

Name of Participant - Typing your name will act as a virtual signature for this document

First Name

Last Name

Name of Participant's Legal Guardian (as needed) - Typing you name will act as a virtual signature for this document

First Name

Last Name

Primary Contact Phone Number

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Today's Date

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Name of the program which I am submitting this form for

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

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*MEDIA RELEASE

By indicating below, I grant permission for "The Moving Self Therapy" to capture and use photo, video, or audio recording of me (or the individual under my guardianship, for cases where legal guardianship is required), with or without my name, while participating in "The Moving Self Therapy" activities.

I understand that these images, videos, or audio files may be used for private supervision and learning purposes, and will be kept private, only shown to professional individuals for the purposes of supervision, teaching, or professional educational settings.

I understand that that these images, videos, or audio files may also be used and adapted for promotional use of "The Moving Self Therapy" programs and services. Promotion may include social media (Facebook, Instagram, Twitter, etc...), as well as website and poster content.

I understand that I am under no obligation to consent to media release. It is my voluntary decision to do so.

YES - I consent to having images, videos, or audio recordings of myself (or the individual in my guardianship) to be used by "The Moving Self Therapy" - for BOTH purposes of supervision/education, AND promotional material.

I agree

YES - I consent to having images, videos, or audio recordings of myself (or the individual in my guardianship) to be used by "The Moving Self Therapy" - SOLELY for the purposes of private supervision/education, NOT for promotional material.

I agree

NO - I do not consent to having images, videos, or audio recordings of myself (or the indvidual in my guardianship) to be used by "The Moving Self Therapy" - for any purposes whatsoever.

I agree

Name

First Name

Last Name