Fall Prevention Class Waiver and Release from Liability

Participation Agreement

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 specify below.

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 including death.
• 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.