Athletic Performance Training
Summer Clinic

I understand that my child is voluntarily participating in physical training and exercise activities under the supervision of Granite State Physical Therapy, PLLC staff.

I/my child am aware that there are significant and inherent risks involved in all aspects of physical training and exercise activities. These risks include, but are not limited to, health incidents, environmental conditions, accidents, falls and other incidents resulting in injuries, including cramps, floor burns, sprains, bruises, muscle injuries, fractures, cardiovascular or pulmonary problems, and other injuries.

I/my child assume all risks in any way connected with or related to physical training and exercise activity and hereby release, waive and covenant not to hold responsible Granite State Physical Therapy, PLLC, or its employees, stakeholders &/or NHTI – Concord’s Community College for any and all claims which I may have relating to personal injury, death, theft or destruction of, or damage to personal property, and from any and all liability whatsoever to me/my child related to my participation in GSPT’s Injury Prevention Program whether caused by negligence of the undersigned, GSPT, PLLC, or otherwise.

I certify that my child has cleared for regular participation in physical activity by primary care physician. I certify that my child is of the appropriate age for participation in this program (entering 6th grade & up).

I give Granite State Physical Therapy, PLLC ‘s staff permission to treat my child in the event of an injury or medical emergency. GSPT staff shall work within their scope of practice and activate EMS as necessary.

Any and all questions about GSPT’s Injury Prevention Program can be directed to Madisen Glaze (madisen@granitestatept.com).

Granite State Physical Therapy has my permission to use my or my child’s photograph or video clips publicly to promote the Athletic Performance Training Clinic. I understand that the images/video clips may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.