*1.Participant Name(Required.)

*2.Session Title(Required.)

*3.Session Date(Required.)

*4.Please read the following and type your name below to acknowledge agreement:

Release from Liability & Acknowledgement of Receipt of Client Bill of Rights

1.      I acknowledge that I have received a copy of the Pathways’ Complementary and Alternative Health Care Client Bill of Rights and understand that documentation of the degrees, training, experience, and education of the Volunteer Provider that I am seeing at Pathways is available to view on the session request page within the online scheduling system.

2.      I understand that Minneapolis Pathways (“Pathways”) is a nonprofit organization dedicated to providing a resource center where persons who face life-threatening health crisis, their family, friends and other interested persons may meet with people in similar circumstances and with unpaid volunteer providers who may provide educational and experiential complementary healing services.

3.      I understand that Pathways is not a treatment center nor does it provide medical care.  I take full responsibility for my medical treatment and for determining that any work done with me by a Volunteer Provider is appropriate for my condition.  I acknowledge that there may be an unforeseen risk of injury or detriment to my health through accepting the services of a volunteer.  I assume full responsibility to ascertain (with any medical advice I may choose) what the nature and extent of that risk may be and to decide for myself whether I wish to accept that risk in accepting the services of a volunteer.

4.      I recognize that Pathways is not responsible for selecting, supervising, reviewing, disciplining or in any way approving any particular content, procedures or services my volunteer provider may provide to me either at Pathways or at other sites.  I also understand that the volunteer providers are not the agents, servants, or employees of Pathways and accordingly Pathways is in no way responsible for any services the volunteer may provide.

5.      My decision to see a volunteer provider at Pathways is my choice alone and consequently, I agree to release, hold harmless and indemnify Pathways, its officers, directors and employees and each volunteer from and against any liability, claim, cost, expense or damage whatsoever arising from my receiving the services from a volunteer at Pathways or other sites.

By signing below I affirm that: (a) I am over the age of eighteen (18) years; (b) this release from Liability is binding on me without the consent or approval of any individual, entity, or court; and (c) I have read, understood and agree to observe this Release from Liability.

Your typed name below acts as a digital signature acknowledging agreement of this form.
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We will send your session login information upon receipt of this form