Functional Movement Screen Request

*First Name
*Last Name
*Gender
 Female  Male  
*Address
*City
*State
*Zip
Home Phone
Cell Phone
Work Phone
*Email
Other Participant(s) Name(s)
Requested Day(s) & Time(s)
 I HAVE READ THE MARCUS JEWISH COMMUNITY CENTER OF ATLANTA RELEASE, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY MY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT INDUCEMENT, ASSURANCE OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE A COMPLETE, CONTINUING AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT OF THE LAW.

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