Positively Fit After Paralysis (October 17 - December 12, 2023)

What best describes you?

• Spinal Cord Injury Survivor
• Person with paralysis OTHER than SCI
• Person with disabling condition OTHER than paralysis
• Family member/Caregiver of SCI survivor
• Family member/caregiver of person with OTHER disability

Please affirm that you will discuss participating in this class with your physician to confirm that such activity is appropriate for you:

• Yes, I will discuss participating in this class with my physician
• No, I already participate in similar activities without objection from my doctor

How did you hear about the class?

• An email from Gathering Strength
• A forwarded email from a friend or colleague
• A flyer I was given or that I saw posted
• Social media such as Facebook, Instagram, etc.
• Traditional media like newspaper (online or otherwise)
• Word of Mouth

I understand that indicating my consent to these questions will be considered the equivalent of my electronic signature, which is the legal equivalent of my manual signature, on an agreement.

• Yes
• No

By choosing to participate in this series of online classes, I understand that I am assuming responsibility for any injury that may occur due to my participation.

• Yes
• No

I understand these classes include moderate to vigorous physical movements and are taught by a qualified instructor(s), nonetheless the possibility of injury (including disability or death) cannot be eliminated.

• Yes
• No

I hereby release and hold harmless the Instructor(s), Gathering Strength, Inc., and its directors, officers, and agents, from liability for any personal injury which may occur to me due to my participation, whether caused by their negligence or not.

• Yes
• No

I hereby waive any and all claims, demands, or actions related to my participation in these classes, due to the conduct of the Instructor(s), Gathering Strength, Inc., and its directors, officers and agents.

• Yes
• No

After completion of this form please check your Spam or Junk folders for our Registration Confirmation email.