SUSOIX Release of Liability and Assumption of Risks

The following information will be used to complete a document that you will read and then sign. Please complete the following form to create the document. You can preview the document you will be signing

Participant Details

First Name *

Middle Name

Last Name *

Participant Date Of Birth *

Gender
Male   
Female   


Participant Address

Address *

Unit #

City *

State *

Zip/Postal *

Country

Participant Contact

Home Phone *

Work Phone

Cell Phone *


E-mail Address *


Can we Email?

Yes

No


How Participant heard about SUSOIX?

Electronic Signature Consent

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

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