Application Form

  • In an effort to provide the most safe and effective programs, we require all clients to complete this application. Information contained on this application will remain confidential. After your application is reviewed, our office will contact you by e-mail or phone.
  • The completion of this application does not guarantee your participation in our program.
  • Contact Information:

  • Please enter a value between 1 and 120.
  • Note: Because we send our client's billing invoices via email, please put your billing address above.
  • About Your Injury:

  • Describe your physical abilities (Be as specific as possible, particularly with respect to your legs):
  • NOTE: All clients over 6 months post injury must obtain a bone density assessment and are required to submit a copy of the bone density report with the doctor’s interpretation before their first session at Journey Forward. We do not interpret bone density reports.
  • Please answer Yes or No to the following. Indicate "Yes" for those that apply to you at present or have applied to you in the past:

  • Excercise

  • In case of Emergency Please Notify:

  • Terms and Conditions:

    I have completed this Application to the best of my knowledge in order to make known any diagnosed medical problems or characteristics that may increase the risk of health problems, signs or symptoms indicative of health problems and lifestyle behaviors related to positive or negative health, which will enable Journey Forward to determine if medical clearance is needed before beginning an exercise program. I understand that if necessary, Journey Forward reserves the right to request medical clearance which may involve a bone scan and physician’s evaluation and approval before beginning any exercise program, and has the right to deny my participation in the program if requests are not fulfilled.

    I also understand that participating in the program at Journey Forward while under the influence of any uncontrolled substance (e.g. marijuana) is strictly prohibited and will result in immediate termination of my participation in the program if detected.

    AGREEMENT

    1. One Week Visit
    At Journey Forward every effort is made to accommodate all schedule changes for our clients. The capacity of our schedule dictates our waiting list, therefore last minute cancellations and constant requests to reschedule makes it difficult for us to accommodate all of our clients. The policy below helps Journey Forward better serve everyone. Thank you for adhering to this policy.

    1.1 Visit Reservation. To guarantee a visitation date, Journey Forward requires an initial deposit of $200 via credit card due at the time of the reservation confirmation. The balance of the total amount due for any visit must be submitted no later than two (2) weeks prior to the arrival date. Full payment must be received prior to the arrival date in order to hold that date on the schedule. If payment is not received, Journey Forward will remove the client from the schedule and provide notification via email.

    All cancellations must be received with at least two (2) weeks notice or the client will be charged a non-refundable fee of $100 taken from the original deposit. Journey Forward will allow a period of six (6) months for rescheduling. If cancellation occurs more than two (2) times in that six (6) month period, the entire deposit will be forfeited. If you have not rescheduled within the six (6) month time period, the entire deposit will be forfeited. If cancellation occurs less than two (2) weeks from the scheduled date, the entire deposit will be forfeited.

    1.2 Initial Consultation. Your initial consultation will consist of approximately 2.5–3.5 hours. During this time, we will go over your paperwork, guidelines, and any questions you may have. Once on the floor, we will do an evaluation of your abilities and the remainder of your appointment working out.

    2. Cost of the Program

    2.1 Cost of One Week Visit: $100 per hour: Five (5) sessions at two (2) or three (3) hours depending on client need and injury level.

    2.2 Ongoing Rates. Current ongoing rate is $100.00 per hour. The pricing is based on the number of hours you train per day per week. Home-based programs are an additional $300. Rates are subject to change at any time.

    3. Payment Schedule for All Clients of Journey Forward, All rates are calculated on a monthly basis. Payment by cash, check, VISA or MasterCard is due on the first of each month. A $100 late fee will apply if payments are not received by the 3rd day of each month and a $75 fee for returned checks. Except as otherwise provided herein, there are no refunds.

    4. Waiver of Liability

    4.1 Waiver/Indemnification. Client acknowledges that any activities client participates in can be an extreme test of client physical and mental limits and carry the potential for severe physical injury. Client hereby assumes the risks of participating in any and all of Journey Forward activities and functions. Client certifies that client is able to participate in the Journey Forward program and has not been advised otherwise by a qualified medical person. Client understands that the information and treatments obtained by participating in Journey Forward do not constitute medical treatment, diagnosis or advice. Client understands that client should seek the advice of a physician or other qualified health provider if client has questions about a medical condition. Client understands that a bone density scan is required to enter Journey Forward and client agrees and acknowledges that Client will have taken such bone density test and shared the results of such test with Journey Forward before beginning any treatments with Journey Forward. Client certifies that in consideration of becoming a client of the program, Client hereby takes the following action for itself, its executors, administrators, heirs, next of kin, successors and assigns:

    Client waives, releases and discharges from any and all claims or liabilities for any loss, damage, theft or injury of any kind which arise out of or related to its participation in, or its traveling to and from the Journey Forward center; including, but not limited to, 1) any known and unknown, foreseen and unforeseen bodily and personal injury, 2) loss of life, and 3) any attorney’s fees, costs, expenses, or charges sustained, directly or indirectly, or alleged to have been sustained, or in any fashion arising from, in connection with, or resulting from its participation in Journey Forward, even if due to the negligence of Journey Forward or any employee, volunteer, director, officer, client, owner or agent thereof.

    Client will indemnify and hold harmless Journey Forward any and all employees, volunteers, directors, officers, clients, owners and agents thereof from any claim, demand and/or cause of action of any nature whatsoever, related to Client’s participation in Journey Forward even if due to the negligence of Journey Forward, including, but not limited to any and all losses, liabilities, damages, costs and expenses (including reasonable attorney fees) arising out of such actions.

    4.2 Termination of Services. Journey Forward reserves the right to terminate the service relationship with clients at any time, for any reason, with or without cause or notice and with no further liability to Client. No oral or written statement shall limit the right to terminate the service relationship.

    4.3 Consent to Use of Materials. By signing this Agreement and joining Journey Forward, you give Journey Forward a perpetual, worldwide, royalty-free, sublicenseable, assignable license to use your name, voice, visual likeness, photographs and film of you (collectively, the "Materials") to use, adapt, modify, reproduce, distribute, publicly perform and display, in brochures, advertisements, commercials, on the Journey Forward website and in any form now known or later developed throughout the world. Client understands and agrees that Journey Forward shall be the exclusive owner of all title and interest, including copyright, in any and all works containing the Materials.

    4.4 Authorization. Client understands that client is personally responsible to pay all charges for services rendered to it and agrees to make payment thereof when due. Any billing sent by Journey Forward to an insurance company, attorney, or other third party is for the accommodation of the Client and does not relieve the undersigned to pay charges for the services provided. Client authorizes any holder of medical information about it to release to its insurance carrier and its agents any information needed to determine these benefits. Client authorizes payment for these services to be paid directly to Journey Forward.

    Client hereby confirms that he/she is 18 years of age or older, he/she has read this document and understand its contents. If under 18, a parent or guardian must sign. Client acknowledges that he/she has read, understands, and agrees to the terms and conditions of this Agreement.

    Release of Liability, Assumption of Risk and Indemnity Agreement for Clients with Diagnosed or Undiagnosed Osteoporosis or Osteopenia I understand that osteoporosis is a disease in which bones become fragile and more likely to break. If not prevented or if left untreated, osteoporosis can progress painlessly until a bone breaks. These broken bones, also known as fractures, occur typically in the hip, spine and wrist.

    Any bone can be affected, but of special concern are fractures of the hip and spine. A hip fracture almost always requires hospitalization and major surgery. It can impair a person's ability to walk unassisted and may cause prolonged or permanent disability or even death. Spinal or vertebral fractures also have serious consequences including, but not limited to, loss of height, severe back pain and deformity.

    By reading and signing this document, I acknowledge that I have been diagnosed with osteoporosis or osteopenia (low bone density) and I understand I am at high risk for fractures. I also understand that the Journey Forwards program requires strenuous physical activity and/or intense exercise in which there are potentially serious risks and dangers including, but not limited to, fractures, disability or even death as described above.

    In light of the above information, I, the undersigned participant, am requesting voluntary participation in the Journey Forward program. I have obtained appropriate medical insurance that will provide for medical treatment in case of accident, illness or injury for the duration of the program. Furthermore, I will use my personal medical insurance as a primary medical coverage payment if accident or injury occurs.

    Release of Liability, Assumption of Risk, and Indemnity Agreement

    RELEASE: In consideration for being permitted to participate in the program for spinal cord-injured clients at Journey Forward that I have enrolled in with a current diagnosis of osteoporosis or osteopenia, I do hereby release and hold harmless, forever discharge and covenant not to sue Journey Forward its owners, officers, staff, employees and/or the agents of each of them, from and against any and all liabilities, claims and causes of action including, but not limited to, negligence, by reason of any personal injury, accident, illness, death or property loss or any other consequence resulting directly or indirectly from or in any manner arising out of, or in connection with, my being a participant in the Journey Forward program.

    ASSUMPTION OF RISK: Participation in the Journey Forward program carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains to 2) major injuries such as bone fractures, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including further paralysis and death.

    INDEMNIFICATION: I also agree to indemnify Journey Forward. and its owners, staff, employees, and agents in connection with any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities including, but not limited to, attorney’s fees, brought as a result of my involvement in the Journey Forward program and to reimburse them for any such expenses incurred.

    I HAVE READ THE PREVIOUS PARAGRAPHS AND I KNOW, UNDERSTAND, AND APPRECIATE THESE AND OTHER RISKS THAT ARE INHERENT IN THE JOURNEY FORWARD PROGRAM. I HEREBY ASSERT THAT MY PARTICIPATION IS VOLUNTARY AND THAT I KNOWINGLY ASSUME ALL SUCH RISKS AND ENTER INTO THIS RELEASE, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT VOLUNTARILY. I FURTHER UNDERSTAND AND AGREE THAT THIS AGREEMENT SHALL ALSO BE BINDING ON MY HEIRS, ASSIGNS, SUCCESSORS, AND ALL OTHER PERSONS WHO MAY CLAIM THROUGH ME.

    Severability: The undersigned further expressly agrees that the foregoing release, assumption of risk and indemnity agreements are intended to be as broad and inclusive as is permitted by the law of the State of Massachusetts and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

    Acknowledgment of Understanding: I have read this release of liability, assumption of risk, and indemnity agreement, I fully understand its terms, and I understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.