MAV October 2017 Participant Information and Waiver

* Asterisk indicated question must be answered.

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* 1. Please enter/update your contact information

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* 2. Preferred name on your certificate - Full name with credentials to be listed.  Unless otherwise directed, the cVMA designation will be added to denote "certified in Veterinary Medical Acupuncture".  i.e. John Doe: "John Q. Doe, DVM, MS, DACVIM, cVMA"  ***If you are a 4th year student, we will automatically add DVM unless you direct us differently***

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* 3. Practice Focus (check all that apply)

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* 4. Do you follow any of the these dietary restrictions? (Please select all that apply.)

PLEASE READ COMPLETELY BEFORE AGREEING

Its effect is to release CuraCore  (hereinafter referred to as Releasee) from any liability resulting from your participation in the activities described below, and to waive all claims for damages or losses against the Releasee which may arise from such activities even if they result from negligence.

RELEASE FROM RESPONSIBILITY, ASSUMPTION OF RISK, AND WAIVER

Locations of Activities that correspond to your Track(s) - Hilton/ARDEC/Hearts & Horses
Dates of Activities that correspond to your Track(s) October 16-19, 2017

DESCRIPTION OF ACTIVITIES: Medical Acupuncture for Veterinarians Course, including participation in lecture/laboratory sessions.  The course includes participation at various locations indoors and outdoors, including animal/equine facilities, transportation between locations and interaction with and proximity to animals, both large animal (equine) and smaller animals (canine). With the release, the Participant acknowledges the inherent risks involved with transportation between multiple locations, risks inherent at various locations, and risks inherent to interaction with and proximity to large and small animals.

I, the undersigned participant, exercising my own free choice to participate voluntarily in the activities and transportation described above, and promising to take due care during each transportation and participation, hereby acknowledge that I have been informed of the nature of the activities and that I am aware of the hazards and risks which may be associated with transportation and my participation in the above-named activities, including the risks of bodily injury, death or damage to property which may occur from know or unknown causes.  I understand, accept, and assume all such hazards and risks, and waive all claims against the Releasee.  I understand that I am solely responsible for any costs arising out of any bodily injury or property damage that I may sustain through transportation and my participating in normal or uncurl acts association with the above-named activities, regardless of whose fault may be the cause of my injuries or damages, EVEN IF CAUSED BY CARELESSNESS OR NEGLIGENCE, so long as the conduct which caused the injuries or damages was not grossly negligent, or willful and wanton.

Further, I hereby indemnify and hold harmless the Releasee, and their members, officers, agents, employees, and any other persons or entities acting on their behalf, and the successors and assigns for any and all of the aforementioned persons and/or entities, against any and all claims, demands, and causes of action whatsoever, whether presently  known or unknown, of any person who suffers any injury, disability, death or other harm, to person or property or both, as a result of my participation in and/or presence at the above listed activities.

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* 5. Initial that you have read the above

As a participant I may elect to engage in the practice of an utilization of certain technology including, but not limited to, laser and electroacupuncture equipment.  I acknowledge, understand, accept, and assume all such hazards and risks associated with my use of all such equipment, and waive all claims against the Releasee.  I hereby indemnify and hold harmless the Releasee, and their members, officers, agents, employees, and any other persons or entities acting on their behalf, and the successors and assigns for any and all of the aforementioned persons and/or entities, against any and all claims, demands, and causes of action whatsoever, whether presently known or unknown, of any person who suffers any injury, disability, death or other harm, to person or property or both, as a result of my utilization  of all technology associated with the course including, but not limited to, laser and electrical stimulation equipment.

If I bring my own animals to class for labs, I am responsible for my animals at all times.  The Releasee is not liable for any harm caused to the animals by other animals who are attending the course. I acknowledge that my animal is not aggressive, not a fear-biter, and does not have an infectious disease, and therefore is eligible to participate.  If my animal companion has medical or behavioral problems, I will let Releasee know in advance.  I understand that if the course faculty or staff notes any medical or behavioral problems that could cause injury, stress, or discomfort to my animal or to others in the vicinity, I may need to cease participation of my animal companion in the labs.

I give permission to the Releasee to take photographs and audio/video recordings of me and/or my animals throughout the recording for the Medical Acupuncture for Veterinarians Program.  I understand that copies may be made and used for promotional purposes (including, but not limited to: brochures, newsletters, displays, web pages as well as educational purposes for use by Releasee in its ordinary course of business.  I further understand that I will not be financially compensated for any such photographs or audio/video recordings and I waive all rights with regard to the same.

I acknowledge that I am to make no audio/video/photographic recording of any onsite sessions.

I have had sufficient time to review and seek explanation of the provisions contained above, have carefully read them, understand them fully, and agree to be bound by them.  After careful deliberation, I voluntarily give my consent an agree to the Release from Responsibility, Assumption of Risk and Waiver.

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* 6. I have read, understood, and agree to the Acceptance form and Release from Responsibility, Assumption of Risk and Waiver.

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* 7. Signature and Date

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* 8. Please enter your clinic/contact information you would like listed in the Find a Practitioner area of our website if different from above:

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