Waterford Place Participant Information Form

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In our efforts to provide helpful resource to all participants and for grant reporting purposes, Waterford Place Cancer Resource Center is requesting family household size and income information. The information you provide will remain confidential. Please indicate family size and estimated annual income level.

I, the undersigned, have voluntarily chosen to participate in the classes / programs / services offered by Waterford Place Cancer Resource Center. I understand that participation in certain classes / programs / services may require physical exertion and a minimum level of physical fitness. I agree to assume all responsibility and liability for all injuries I may sustain due to my participation in these activities. In consideration for participation in the classes / programs / services, I agree to release, acquit and discharge Waterford Place Cancer Resource Center, Rush Copley Medical Center and Copley Memorial Hospital of and from any and all liability of any kind or nature, including theft or loss of personal property on account of or in any way related to my participation at Waterford Place Cancer Resource Center and Rush Copley Healthplex. I further understand and agree that failing to show for two (2) complementary therapy services appointments will result in forfeiting all future complementary therapy services appointments.