Name *

First Name

Last Name

Phone *

(###)

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Today's Date *

MM

DD

YYYY

Release of Liability *

I recognize that I am in charge of my own body and my own safety. In choosing to participate in the services offered by The Winchester Institute, I hereby release The Winchester Institute of Chiropractic Health and Wellness and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf in any way arising out of or connected with my participation in activities of The Winchester Institute or the use of any equipment used.

I release any responsibility or liability from The Winchester Institute of Chiropractic Health and Wellness