By my signature below, I acknowledge, understand, and agree that I am voluntarily
participating in the “Stepping On” Program (“Program”), beginning on the date I
Participation in the program includes, but is not limited to
light exercises and demonstration of getting up from a fall as well as assisted
mobility and education and instruction
in evidence based fall prevention principles.
By my signature below, I further acknowledge, understand, and agree that:
Participation in the program is voluntary.
I understand that this program, while intended to reduce falls, is not a guarantee
that all falls will be prevented. This program is meant as a supplement to
knowledge and physical therapy.
I understand that there is some risk of injury including but not limited to
heart attacks, muscle strains, muscle pulls, muscle tears, broken bones, shin
splints, injuries to knees, back, feet, joints and other illness or soreness
Should I suffer any physical injury or financial loss as a result of my participation
in the program, I will not seek any payment or financial compensation for such
injury or loss from COPC, its employees, agents, directors, officers and affiliates.
COPC cannot and does not guarantee my safety during this Program.
I assume full responsibility for any risk, injuries or damage known or unknown
which I might incur as a result of participating in the Program and waive any
claims of personal injury or death associated with my participation in the Program.
I understand and confirm that by signing this waiver and release I have given
up future legal rights. I have signed this waiver and release freely, voluntarily,
and under no duress.
My signature is proof of my intention to execute a complete and unconditional waiver
and release of all liability to the fullest extent of the law. I am 18 years of age
or older and mentally competent to enter into this waiver.