Consent and Release Form

Question Title

* 1. Please Provide Your Contact Information:

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

Question Title

* 2. Do you consent to the following:

I absolve and release the New York State Department of Health, Bureau of Occupational Health and Injury Prevention and its funders, and Nassau University Medical Center, Sloan Yoselowitz , and their officers, employees and agents from any liability for any personal injury or other concern arising out of or in any way connected to my participation in this falls prevention workshop.

I voluntarily agree to these terms and conditions.

Yes

No

Question Title

* 3. Electronic Signature