Please complete the form below: *

I verify that all information is correct and current to the best of my knowledge. I understand that I will be participating in a movement and/or manual therapy program from LevelUp Neuro Performance that may require body manipulation and physical exertion. 

I understand that by signing this statement, I am agreeing not to hold LevelUp Neuro Performance or any of its employees, owners, agents or insurers responsible for any bodily injury or property damage that I may suffer as a result of my participation in a movement and/or manual therapy program through LevelUp Neuro Performance, whether at LevelUp Neuro Performance, at home, or elsewhere. As such, I understand and agree that LevelUp Neuro Performance, its employees, owners, agents or insurers shall not be liable for any bodily injury or property damage that may result either directly or indirectly from my participation in a program through LevelUp Neuro Performance.

Name *

First Name

Last Name

Parent or Guardian (if client is under 18)

First Name

Last Name

Date *

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