WARNING: BY SIGNING THIS DOCUMENT YOU WILL WAIVE CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE. PLEASE READ THOROUGHLY AND CAREFULLY BEFORE SIGNING!!!

TO: SMART PT INC. & JONATHAN REIMER (the “Course Providers”) 

RE: SPINAL MANIPULATION EDUCATION PROGRAM (the “Course”)

YOUR LEGAL NAME:   

YOUR ADDRESS:   

THE UNDERSIGNED ACKNOWLEDGES THAT:

1. The undersigned is aware that manual spinal manipulation is a skillful, passive, high velocity, low amplitude, minimal force thrust movement of a joint beyond its active limit of motion but within the limits of its anatomical integrity for the purpose of restoring motion and function and, as with all therapies, that there are risks associated with such treatment. The undersigned further acknowledges that the Course Provider has reviewed the risks associated with such treatment with the undersigned and other Course participants including, but not limited to, fainting, severe headaches, cranial nerve signs and symptoms, fracture, stroke, paralysis and even death.

2. The teaching of spinal manipulation involves both theory and practice and that in order to help develop such skills while participating in the Course participants are often in the role of both practitioner and patient. Sometimes the undersigned will be the person practicing spinal manipulation techniques and sometimes the undersigned will be the person upon whom another participant in the Course is practicing spinal manipulation techniques. The undersigned does hereby CONSENT TO AND AUTHORIZE the Course Provider and other participants in the Course to perform spinal manipulation on the undersigned and the undersigned does freely and voluntarily accept and fully assumes all such risks, dangers and hazards and the possibility of personal injury, death or loss, resulting from participating in such activities, whether specified or not. Notwithstanding the foregoing, the undersigned has the right to stop the application of spinal manipulation techniques on the undersigned and withdraw his/her consent at any time by verbally indicating the withdrawal of consent at the specific time in question to the person practicing spinal manipulation techniques on them and the Course Provider or, if withdrawing completely, by providing written notice to the Course Provider. The undersigned is advised not to continue to participate in spinal manipulation if they feel unwell, or unable or unfit to continue safely. Consent to participating as a patient is not required to complete the Course.

3. The undersigned is responsible for informing the Course Provider, and has informed the Course Provider, of all health conditions, issues and concerns that may be impacted by spinal manipulation, including suspected fractures, osteoporosis, malignant and inflammatory diseases, connected tissue disorders, blood diseases, neurological disorders, mental disorders, medication such as anticoagulants, and pregnancy. Continued participation by the undersigned as a volunteer patient in the Course will be deemed a waiver of any liability upon other course participants and the Course Provider for any such health conditions, issues or concerns.

4. The use of spinal manipulation treatment for a patient is a skill that requires working within their personal level of competence, including the use of the proper technique in the right circumstances for the treatment of disorders related to the neuromusculoskeletal system, together with due care and attention by the treatment provider. The undersigned is responsible for determining if spinal manipulation is an appropriate course of treatment for their patient and the Course Provider cannot be responsible and is not liable for the improper use of or deviation from spinal manipulation techniques.

5. In order to legally practice the use of spinal manipulation on a patient the undersigned must be adequately educated and trained, and validly registered to practice spinal manipulation on the General Register with the College of Physical Therapists of Alberta.

IN CONSIDERATION OF the Course Provider providing instruction in spinal manipulation to the undersigned, the undersigned agrees as follows:

1. TO WAIVE ANY AND ALL CLAIMS that the undersigned has or may have in the future against the Course Provider, and their next of kin, heirs, personal representatives, executors, administrators, successors and assigns.

2. TO RELEASE THE Course Provider from any and all liability for any loss, damage, injury or expense that the undersigned may suffer, or that the next of kin or heirs of the undersigned may suffer as a result of the participation of the undersigned in the Course due to any cause whatsoever INCLUDING NEGLIGENCE, BREACH OF CONTRACT, OR BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE.

 (Initial here that you have read paragraph 2)

3. TO HOLD HARMLESS AND INDEMNIFY the Course Provider from any and all liability for any personal injury to, or damage to the property of, any third party caused by the undersigned.

4. This Waiver, Release and Assumption of Risks is governed by and construed in accordance with the laws of the Province of Alberta and the federal laws of Canada applicable therein. The undersigned does hereby irrevocably and unconditionally submit and attorney to the jurisdiction of the courts of the Province of Alberta in connection with any disputes or other matters arising out of or in connection with this Agreement.

5. This Agreement shall be effective and binding upon the undersigned and the respective next of kin, heirs, personal representatives, executors, administrators, successors and assigns of the undersigned in the event of the death or incapacity of the undersigned.

The undersigned acknowledges that the undersigned is not relying upon any oral or written representations or statements made by the Course Provider other than what is set forth in this Agreement.