NEW CLIENT APPLICATION

   If you are interested in becoming a part of the CORE program, fill out and submit the form below  

Client Information

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Address Line 1
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Neurological Condition

Physician Information

Billing Information

Emergency Contact

Short Term Goals

WAIVER AND RELEASE FROM LIABILITY FOR USE OF CENTER OF RECOVERY & EXERCISE (CORE)

I, (name on appliccation) , HEREBY WAIVE AND RELEASE, indemnify, hold harmless and forever discharge Center of Recovery and Exercise (CORE) and its agents, employees, offices, directors, affiliates, successors, and assigns, of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages and liabilities of every kind and nature, whether known or unknown, in law or equity, that I ever had or may have, arising from or in any way related to my participation in any of the events or activities conducted by or on the premise of for the benefit of the CORE. Client acknowledges that any activities client participates in can be an extreme test of client physical and mental limits and carry the potential for severe physical injury. Client hereby assumes the risks of participating in any and all of the CORE program and has not been advised otherwise by a qualified medical person. Client understands that the information and treatments obtained by participating in CORE do not constitute medical treatment, diagnosis or advice. Client understands that client should seek the advice of a physician or other qualified health provider if client has questions about medical condition. Client understands that a bone density scan is required to enter CORE and client agrees and acknowledges that Client will have taken such bone density test and shared the results of such test with CORE before beginning any treatments with CORE. Client certifies that in consideration of becoming a client of the program, Client hereby takes the following action for itself, its executors, administrators, heirs, next of kin, successors, and assigns. Client waives, releases and discharges from any and all claims or liability for any loss, damage, theft or injury of any kind which arise out of or related to its participation in, or its traveling to and from the CORE facility; including but not limited to 1) any known and unknown, foreseen and unforeseen bodily and personal injury, 2) loss of life, and 3) any attorney's fees, costs, expenses, or charges sustained, directly or indirectly, or alleged to have been sustained, or in any fashion, arising from, in connection with, or resulting from its participation in CORE. Client agrees to the utilization of any video(s)/photo(s) taken at CORE to be utilized for education, promotional advertising, and marketing purposes.
By typing your name, you are agreeing to the terms above.

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