The Diabetes Rewind Seminar is an educational seminar offered as a free public service to this community. This seminar is a six-week health education program. It provides information to assist individuals with Type 2 Diabetes in making informed lifestyle changes that may aid them on their road to restored health.

I understand that I may expect some of the following physical changes in response to implementing aspects of the health education I receive during the Diabetes Rewind Seminar:

I accept full responsibility for informing my physician of my participation in the Diabetes Rewind Seminar. I agree that I will consult with my personal physician before making any changes in my medications, including reductions or discontinuations.

To the best of my knowledge, I have no physical or medical conditions that would be adversely affected by participating in the Diabetes Rewind Seminar. I will inform my physician should I experience any medical problems, if I choose to implement aspects of the health education I receive while attending the Diabetes Rewind Seminar.

I understand that this Diabetes Rewind Seminar is not intended to take the place of my physician's care, but rather is to supplement that care by providing disease education, as well as diet and exercise instruction.  I will not hold the Diabetes Rewind Seminar volunteers liable for any personal harm or injury of acts of negligence. I take full responsibility in becoming informed about the process of my disease.

I have carefully read this form before I signed it and have had an opportunity to ask questions about the Diabetes Rewind Seminar and the possible risks. My questions have been answered to my satisfaction. I also understand that I am free to ask any questions pertaining to the Diabetes Rewind Seminar at any time.

I understand and agree that entering my name in the box below constitutes my digital signature and legal consent to the statements above.