ICP Grad Sign Up

General Information

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First Name*

Last Name*

Date Of Birth*

Email*

Affiliation to Home Base*

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When did you attend the ICP Program *Best Estimate

How did you hear about the ICP Grad Program?

MGH Home Base ICP Graduate Program Liability Waiver and Release

RULES:

I agree to comply with all rules and regulations set by the Home Base ICP Graduate Program. I understand and agree that participation is at the sole discretion of management and that disregard for any rules or regulations may result in termination of participation.

I affirm to comply with all Rule and regulations (Please Check)*

RELEASE:

I agree that if I engage in any physical exercise or activity, as a part of the Home Base ICP Graduate Program, that I do so at my own risk. In addition, I agree that none of the Home Base Program, Massachusetts General Hospital, Massachusetts General Brigham Healthcare System, or Red Sox Foundation, or their staff, are in any way responsible. I agree that I am voluntarily participating in all designated ICP Graduate Program physical exercises, programs, or activities and assume all risk of injury, illness, damage, or loss to me or my property. I understand that the Home Base ICP Graduate Program does not offer diagnostic services or medical care; nor does it create any physician-patient relationship between you and program staff. If I have questions or concerns about my health at any time, before, during or after the program, I should contact my primary care physician as soon as possible. I acknowledge that I have read this Waiver and Release and fully understand that it is a release of liability. I hereby represent and warrant that I am at least 18 years of age and of sound mind and body, and I am capable of giving this release on my behalf.

I understand and consent to all of the release requirements (Please Check)*

THIS WAIVER OF LIABILITY IS FOR THE MASSACHUSETTS GENERAL HOSPITAL HOME BASE ICP Graduate Program

I HEREBY AFFIRM THAT I HAVE READ THIS RELEASE, AND THAT I FULLY UNDERSTAND ITS TERMS. I FURTHER AFFIRM MY UNDERSTANDING THAT, BY COMPLETING THIS REGISTRATION, I AM GIVING UP SUBSTANTIAL RIGHTS, INCLUDING THE RIGHT TO SUE. I ACKNOWLEDGE THAT I AM COMPLETING THIS REGISTRATION FREELY AND VOLUNTARILY, AND THAT I INTEND TO BE BOUND BY THIS AGREEMENT TO THE FULLEST EXTENT ALLOWED BY LAW.

If you agree to all the above information, please type your name below, as a digital signature*

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