Date: 
  September 10

Location: 


  Glenwood Gardens

  10397 Springfield Pike, Cincinnati, OH  45215

Check-in/T-shirt pick-up: 
  7:30 AM (follow signs at trail head)
Official Rehearsal Time: 
  8:00 AM

Flash Mob Time:

(shhhh   - 

  During Opening Ceremony (10-10:30 am​)

 it's a surprise flash mob)


Thank you for registering to participate in #ShakeIt for Self-Acceptance!  Participants under 18 are welcome WITH parent/guardian signed release and consent.

We are thrilled you will be joining Tri-State Eating Disorder Resource Team for a flash mob of #ShakeIt for Self-Acceptance!®  at Glenwood Gardens on Saturday, September 10. Participating in this event does not register you to participate in the Cincinnati, OH NEDA Walk.  We are sincerely grateful and appreciative that you have taken time out of your busy schedule to invest your time, energy and resources. With your help, it is our intention for this flash mob to inspire the important message and joy of self-acceptance.  The first 50 to register/participate in the #ShakeIt For Self Acceptance® Flash Mob Dance will receive a free t-shirt and a code via email to cover the registration fee for the Cincinnati NEDA Walk.


REGISTRATION for the Cincinnati, OH NEDA Walk is at www. nedawalk.org/cincinnati2016

What You Can Expect/How You Can Prepare:
FOR A TRAINING VIDEO/DANCE TUTORIAL - VISIT  www.ShakeItforSelfAcceptance.com

(password: NEDA).

Please CHECK-IN at 7:30 AM at the trail entrance (we will have signs directing you) to pick up your t-shirt for #ShakeIt for Self-Acceptance!®. We are honored, Allison Spotts-De Lazzer, MA, MFT, LPCC, CEDS, founder of  #ShakeIt for Self-Acceptance!®  will be here to lead the official FLASH MOB REHEARSAL at 8:00 AM (sharp!).


Please complete all fields - use NA if the field does not apply to you - THANK YOU!

RELEASE AND ASSUMPTION OF RISK

Thank you for participating in #ShakeIt for Self-Acceptance!® at the Cincinnati, OH NEDA Walk, hosted by Tri-State Eating Disorder Resource Team, Inc. Please read this form carefully and be aware that in signing up and participating in this Event, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss, including death, which you or your child might sustain as a result of participating in any and all activities connected with and associated with the Event. 

NEDA is committed to conducting its programs and activities in a safe manner and holds the safety of participants in high regard. NEDA also strives to reduce the risks of the Event and insists that all participants follow safety rules and instructions that are designed to protect the participants’ safety. However, you must recognize that there is an inherent risk of injury when choosing to participate in these types of events. You (the “Participant”) are solely responsible for determining if you or your child is physically fit and/or adequately skilled to participate in the Event. It is always advisable, especially if the Participant is pregnant, disabled in any way, or recently suffered an illness, injury, or impairment, to consult a physician before undertaking any physical activity. You are also solely responsible for selecting and wearing personal protective equipment. Despite careful and proper preparation, instruction, medical advice, conditioning and equipment, there is still a risk of injury, including death from participating in the Event and it is impossible for NEDA to guarantee your absolute safety.

I recognize and acknowledge that there are certain risks of physical injury to participants in this Event and I voluntarily agree, as a condition of my and/or my child’s participation in the Event, to assume the full risk of any injuries, costs, damages or losses, regardless of severity, that my child or I may sustain as a result of participating in any and all activities connected with or associated with this Event. I agree to waive and relinquish all claims, specifically including those for any injury (including death), costs, damages and/or losses arising out of or otherwise incidental to participation in the Event, that I or my child may have as a result of participating in this activity, against NEDA including its officers, officials, agents, employees, representatives, volunteers and servants, (both individually and collectively). On behalf of myself and/or the child identified above, I do hereby fully release and forever discharge the NEDA from and against any and all claims for injuries, damages or loss, including death, that my child or I may have arising out of, connected with, or in any way associated with this Event. This waiver and release shall apply to any and all actions, causes, damages, claims, or demands of every kind, whether known or unknown, arising out of or otherwise incidental to participation in the Event. On behalf of myself and/or the child identified above, I hereby agree to indemnify, hold harmless, and defend NEDA from and against any and all liability or claims for loss, damage, or injury to person or property, or of any other kind, whether known or unknown, including your person and property and including claims for attorney’s fees, arising out of or otherwise incidental to your participation in the Event. While participating in the Event, you agree to obey all rules, regulations, and laws of the United States and the state and locality where the Event is held. You agree to obey all rules, regulations and policies of the NEDA associated with the Event. You agree that your violation of the above rules, regulations, laws or policies (as determined in the sole discretion of a NEDA representative) may result in your expulsion from the Event.

In conjunction with NEDA, TSEDRT, and #ShakeIt for Self-Acceptance!®’s possible use of my appearance or of materials supplied by me in photos, videos and promotional materials about the Event, NEDA, TSEDRT, and #ShakeIt for Self-Acceptance!® may use my name, likeness, voice, biographical information and the material supplied by me (“Biographical Information”) for the purposes of advertising, publicity, fundraising and promotion associated with the Event. I understand that NEDA, TSEDRT, and #ShakeIt for Self-Acceptance!® will own any such photos or materials from the Event that may include my Biographical Information and will have the right to use and reuse, modify, adapt and create derivative works of them.

I have read and fully understand the above. If registering on-line or via fax, my on-line or facsimile signature shall substitute for and have the same legal effect as an original form signature.  Individuals under 18 must have a parent/guardian signature representing consent/release..

Parent/Guardian/Participant represents that that she/he is executing this agreement voluntarily.