LSVT BIG Volunteer Registration and Consent

Thank you for your interest in volunteering for our interactive sessions with physical and occupational therapy professionals and students. Please complete the following information and submit your responses. We will be in touch about details on upcoming volunteer events.

First name*

Last name*

Phone number*

Street address*

City*

State/Province*

Zip/Postal Code*

Email*

Your Emergency Contact:
Please provide an emergency contact name and phone number who will be available during the session to assist you in case of an emergency. This information will not be used except for emergency.

Name of Emergency Contact*

Emergency contact's phone number, with area code. (Provide the country code if you are joining from outside the United States):*

Privacy Policy: Please review the following details concerning our Privacy Policy.

In order to protect the privacy of my fellow participants:

I will not video record, audio record, take photos or computer screen shots of the session.
I will identify anyone who is in my room with me to the other session participants.
I will not share information about other people in the session.

Voluntary Participation: In consideration of the opportunity to volunteer for the interactive exercise session presented by LSVT Global, Inc., I hereby confirm my understanding and agreement to the following:

Description of Activities:

I will be a volunteer participant for a group of physical (PT) or occupational therapists (OT), PT/OT students, and/or PT/OT Assistants who are taking this course and learning how to perform the LSVT BIG protocol. The LSVT BIG protocol involves whole body exercises and movements in sitting and standing positions.
I understand that this interactive session will include movements and exercises using the whole body and will not be considered medical care or treatment. My participation in these exercises will be at no cost to me and will provide therapists and/or students the opportunity to enhance their learning of the applicable protocol.
I acknowledge and agree that my participation will include only part of the protocol, is not intended to address specific goals and will not include a physical or medical evaluation. The aforementioned exercises, and any related activities in which I may participate are referred to as “Activities”. There will be a trained course instructor available (via Zoom or other video conferencing system) to provide remote supervision and feedback to me and the course participants.
I agree to comply with all instructions relating to the Activities, to promptly advise my assigned instructor if I need help, become concerned for my safety, experience any discomfort or injury, or wish to discontinue my participation in the Activities. I understand that my participation in the Activities is optional. I understand that I may discontinue my participation in the Activities at any time.

Volunteer Information

How long have you had Parkinson's disease?*

List at least two changes in your mobility or daily function that have resulted from your Parkinson's disease:*

I have read the LSVT Global Terms of Use and the LSVT Privacy Policy. I fully understand their contents, understand they contain an assumption of risk and release of liability and sign it of my own free will. I understand the release is a promise not to sue and release and indemnity for all claims, including my right to sue for damages caused or alleged to be caused by other's negligence or willful misconduct.

First and Last Name Serving as Signature*