Continuing Education Student Waiver
Please complete this waiver form before participating in your continuing education course. Your responses are confidential and required for participation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Course or Program Title
*
Emergency Contact Name and Phone Number
*
Waiver and Release Agreement: By checking this box, I acknowledge that I have read and understood the risks associated with participating in the continuing education course, and I agree to release the institution and its staff from any liability.
*
I have read and agree to the waiver and release terms.
Signature (Please sign below to confirm your agreement)
*
Date of Signing
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Waiver
Submit Waiver
Should be Empty: