By registering for a support group, I acknowledge that I have agreed to participate in a Chronic Pain Support Group (“support group”) organized by Pain Connection, a program of U.S. Pain Foundation, Inc. I understand that the support group will include discussion of healthcare, work and family issues and the management of chronic pain and that the level of my participation in this support group and any group activities must be determined by me, in consultation with my physician or other qualified healthcare provider. I further understand that the support group leaders are volunteers and people with pain who have undergone training with U.S Pain Foundation, Inc. and that they may not be physicians, psychiatrists, psychologists or other trained healthcare professionals. The support groups are provided for education and support - they are not therapy groups. U.S. Pain Foundation, Inc. is dedicated to serving those who live with pain conditions and their care providers, but does not advocate any one particular treatment for any one type of pain.
I acknowledge that the support group leaders and/or U.S. Pain Foundation, Inc., by making this support group available, are not undertaking any responsibility regarding my medical condition(s). If I feel that my medical condition(s) are adversely affected by my participation in the support group, I understand that it is my responsibility to discontinue participation and to immediately consult with my healthcare provider about continuing or resuming participation.
I agree that all information obtained in the support group is to be considered confidential and I shall hold the same in confidence, shall not disclose, publish or otherwise reveal any of the confidential information received from any participants in the support group and/or U.S. Pain Foundation, Inc. to any other party whatsoever.
All the provisions of this release and waiver shall also apply to a support group conducted by video and/or telephone-conferencing, which may be less secure than in-person support groups, and I fully understand the nature and extent of the potential risks involved with participation in a support group using these forms of electronic media. I agree not to make any type of recording (audio and/or video) of the support group.
I hereby, on behalf of myself, my heirs, executors, administrators, and assigns, assume the risks associated with participation in the support group and release, indemnify and hold harmless the support group leaders, U.S. Pain Foundation, Inc. and it’s agents, officers, members, volunteers and employees from any and all claims, demands, for personal injuries, costs, expenses, and any other loss to person or property arising out of or resulting from my participation in the support group.
I have read this waiver and release and confirm that I am aged eighteen or over. I have been given the opportunity to ask any questions and I fully understand and agree to the above.
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