Republic United

This form authorizes 417 Performance Chiropractic & Sports Rehabilitation ("Provider") to conduct an injury screening on the minor identified below during a workshop event. Participation in the screening is entirely voluntary. However, this signed consent form is required before any screening will be performed.

Description of Screening

The injury screening may include a brief physical assessment of posture, range of motion, joint mobility, movement patterns, and/or areas of reported pain or discomfort. The screening is educational and observational in nature and does not constitute a diagnosis, medical treatment, or establishment of a doctor-patient relationship.

Parental/Guardian Consent

I, the undersigned, am the parent or legal guardian of the minor identified above. I voluntarily give my consent for the Provider to conduct an injury screening on my child at the workshop event described herein. I understand that I may or may not be physically present during the screening and that this consent remains valid regardless of my presence.

Assumption of Risk & Waiver of Liability

I understand that physical screening involves inherent risks, including but not limited to temporary discomfort or soreness. I voluntarily assume all risks associated with my child's participation. I, on behalf of myself, my child, and our heirs, assigns, and representatives, hereby release, waive, and discharge 417 Performance Chiropractic & Sports Rehabilitation, its owners, employees, agents, and volunteers from any and all claims, demands, actions, or causes of action arising out of or related to the injury screening, except in cases of gross negligence or willful misconduct.

Voluntary Participation

I acknowledge that my child's participation in this screening is completely optional and that my child may withdraw at any time without penalty or consequence. I further acknowledge that this signed waiver is required as a condition of participation and that no screening will be conducted without it.