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Adjusting Technique Release Form

In consideration of my participation as an attendee at the seminar sponsored by ICPA, Inc., I hereby release and forever discharge ICPA – including, its officers, directors, employees, agents, instructors, successors, heirs and assigns. In addition to, all other persons, firms, and corporations of and from any and all claims, demands, indebtedness, rights and causes of action, costs, expense, compensation or consequential damage, which I now have or may have against ICPA. This includes but is not limited to any and all claims and demands, right and causes of action of any kind that I now have or hereafter may have, on account of, or in any way growing out of, personal injuries, emotional stress, psychological or psychiatric injury, death and any damages, known or unknown resulting from my participation as an attendee at a seminar sponsored by ICPA. This includes but is not limited to, my active participation in receiving instruction verbally or manually, from any speaker of the ICPA to instruct, guide and/or apply chiropractic adjustment or otherwise, to me at the seminar.

Furthermore, by execution of this Release, I acknowledge and confirm that any instruction that I receive, either in the form of verbal or physical instruction of a chiropractic technique, does not constitute a doctor-patient relationship in any manner whatsoever the same being expressively denied/rejected by me.  Furthermore, by execution of this Release I acknowledge that any participation by me at a seminar sponsored by ICPA, Inc. is voluntary participation in providing and/or receiving instruction from any of the speakers at the ICPA seminars. No promise or inducement which is not herein expressed has been made to me in executing this Release, I do not rely upon any statement or representation made by any person, firm, or corporation, hereby released, or any agent, physician, doctor or any other person representing them. I further understand that this is an unconditional, unqualified Release and includes all claims of every kind, character or nature. This Release expressly insures to the benefit of every person, firm, or corporation or legal entity that might have been legally liable by reason of any such incident.

I further state that I have read the Release, know the contents thereof, and sign the same as my own free act.