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Participation Information Form

Welcome to LivingWell Cancer Resource Center. Please take a moment to complete this confidential participant form. Your personal information will not be shared with anyone outside of LivingWell Cancer Resource Center.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Other Family Members In Household Participating In Programs:
  • Date Format: MM slash DD slash YYYY
  • Release and Waiver:
    I, the undersigned, acknowledge that I have voluntarily chosen to participate in the classes/programs/services offered by LivingWell Cancer Resource Center. I am aware that participation in some of these classes/programs/services may require physical exertion and a minimum level of physical fitness. I am voluntarily participating in the classes/programs/services and I assume all responsibility and liability for any and all injuries I may sustain due to my participation in these activities. In consideration for participation in the classes/programs/services I waive any claims or liability against LivingWell Cancer Resource Center and/or the LivingWell Cancer Resource Center staff/instructors/other participants for injury or damages that I may sustain as a result of my participation. I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.
  • or if participant is under eighteen years old Parent/Guardian Signature*
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.