mPEAK 3-Day Intensive: October 27-29, 2023 RegistrationAfter you submit this form, you will be directed to a payment page. Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Age * Race/Ethnicity (optional) Gender Identity (optional) Why are you interested in participating in this program? Is there anything else that would be helpful for your mPEAK Team Coaches to know at this time? I accept full responsibility for my health and voluntarily complete this Acknowledgement and Waiver of Liability. I understand and agree that the services and tools offered by mPEAK Team (offered by Dr. Carli Kody, Ben Durbin, Jessica Padilla Bowen, and other teachers/coaches, are not intended to replace or be substituted for medical or psychiatric care. It is recognized that the trainings inherent in the programs may at times make participants feel vulnerable. mPEAK Team Specialized Trainings and the mPEAK Course are not therapeutic interventions for psycho-pathological disorders as defined in the DSM, and are not intended as such. By completing this release and consent I assume all risk for any physical or mental consequences of participating in the program. By signing this Acknowledgement and Waiver of Liability, I also specifically and expressly agree to hold harmless, indemnify and release the teachers of this course, mPEAK Team, and Carli Braun Kody, PhD, LP, LLC, its officers, employees and agents from any and all liability for the results of the educational guidance that will be or have been provided. Moreover, I acknowledge that the particulars shared in these classes by other participants are to be maintained as confidential. I will not blog or otherwise report on content shared in these classes in any form of media. By typing my name below, I am indicating that I understand and accept the above terms of this Participation Acknowledgement and Waiver of Liability. * Thank you!
