Walking, Talking, Sunshine! Offered twice per month by the Schmieding Center from 9:00 AM to 10:00 AM at Orchards Park (Bentonville) on the 2nd Thursday or at Gulley Park (Fayetteville) on the 4th Thursday "*" indicates required fields Step 1 of 3 33% AGREEMENT IS REQUIRED FOR PARTICIPATION * RequiredI have carefully read the Schmieding Center’s Release and Waiver of Liability Statement and understand it to be a release and waiver of all potential claims and causes of action for my injury or death or damage to my property that occurs while participating in programs offered by the UAMS Schmieding Center, either in-person or via technology, and it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligent or intentional act(s) or omission(s). I agree to the Schmieding Center’s Release and Waiver of Liability Statement Today's Date MM slash DD slash YYYY Enter required information below. * Required First Last Email * Required Phone * RequiredResidence CountyBentonWashingtonMadisonBaxterBooneCarrollIzardMarionNewtonSearcyStoneotherGenderMaleFemaleOtherRaceAfrican-AmericanAmerican IndianAsian/Pacific IslanderCaucasianHispanicMiddle EasternOtherProfessionPublic/CommunityDieticianMedical StudentNursingNursing Home AdministrationParaprofessionalPatientPhysical TherapyPhysicianResidentSocial WorkStudentHow did you learn of this program?My Center on Aging (the Schmieding Center)My Healthcare Provider referralWebsiteFacebookWord of mouthOther CONSENT TO USE MEDIA IMAGES FOR PROMOTIONS I hereby give the University of Arkansas for Medical Sciences, their legal representative, assigns, and those acting on their behalf and with their permission, the right and permission to copyright in any part of the world, to use, reuse, publish and republish, in conjunction with my own or fictitious name, any photograph, film or video tape recording taken of me by the University of Arkansas for Medical Sciences or those acting on their behalf or with their permission, and any reproductions thereof, in any form, whether intentional or otherwise, and may be used in conjunction with any advertising material, for any purposes of trade, advertising, exhibit, publicity, or promotion, without restriction or limitations. I understand that the photographs, film and/or video may be used in news releases, newspapers or magazine articles, television, the UAMS website or social media sites (e.g., Facebook , YouTube). I hereby release, discharge, and agree to save harmless the University of Arkansas for Medical Sciences, their assigns, legal representatives, agents, and those acting on their behalf and with their permission, from and against any liability resulting from any distortion, blurring, alteration or use in composite form, whether such was intentional or otherwise, which my occur, result, or be produced in the taking of said photography, or by processing or reproduction of the finished product, its publication or the distribution of same. I waive the right to approve or inspect the recordings, advertising copy, or material used in conjunction therewith.I consent, per above terms, to the use of my image by UAMS for program and event promotion Yes No
