Dublin, GA – CSB of Middle GA – Recertification
Hosted by: CSB of Middle Georgia
Dublin, GA – April 22, 2025 – 8:30am – 4:00pm – Recertification
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Acknowledgment of Acceptable use of Certification and Materials
I hereby acknowledge that the materials owned by Intervention Support Services, LLC, a Georgia limited liability company doing business as Mindset Safety Management and MindSet Instructor Training, are the property of Intervention Support Service, LLC, and are proprietary in nature. These materials are to be used solely and exclusively by MindSet Trainers and those they train within their own organization. In addition, materials are only to be used in accordance with the MindSet Tenets and Guiding Principles in creating a culture of prevention. Using MindSet to support, market, or advertise other products and services is only allowed with expressed written consent. Furthermore, As certified instructors of the MindSet Curriculum, I acknowledge I am authorized to train individuals only within the organization with which I was employed upon time of training.
RELEASE, WAIVER OF LIABILITY AND ASSUMPTION OF RISK
I hereby acknowledge my awareness that my participation in one or more Mindset Safety Management training sessions may expose me to risk of personal injury. I acknowledge that Mindset Safety Management training involves physical activity and therefore there is risk that I may be injured as a result of my participation in such training.
For the sole consideration of Intervention Support Services, LLC, a Georgia limited liability company doing business as Mindset Safety Management providing such training, I hereby release, forever discharge AND COVENANT NOT TO SUE Intervention Support Services, LLC and its members, directors, officers, consultants, agents and employees (COLLECTIVELY HEREIN REFERRED TO AS “RELEASEES”) from any and all LIABILITY, CLAIMS, DEMANDS, ACTIONS AND CAUSES OF ACTION OF WHATEVER KIND ARISING FROM OR RELATED TO ANY LOSS, DAMAGE, COST (INCLUDING MEDICAL COSTS) OR EXPENSE OF ANY PERSONAL INJURY (INCLUDING DEATH) SUSTAINED BY ME, OR TO ANY PROPERTY BELONGING TO ME, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, RESULTING FROM OR IN ANY WAY CONNECTED WITH MY PARTICIPATION IN THE TRAINING.
I certify that I am at least eighteen years of age, THAT I INTEND FOR THIS RELEASE, WAIVER OF LIABILITY AND COVENANT NOT TO SUE TO BIND THE MEMBERS OF MY FAMILY AND SPOUSE (IF ANY), IF I AM ALIVE, AND MY HEIRS, ASSIGNS AND PERSONAL REPRESENTATIVE, IF I AM NOT ALIVE, and that I have read and understand the above. I further agree that this Release, Waiver of Liability and Assumption of Risk shall be governed by the laws of the State of Georgia.
Video and Pictures Release
I, hereby grant permission to Intervention Support Service, LLC, to use photographs and/or video footage taken of me on the MindSet Instructor Training for the following purposes:
- Use in promotional materials, including but not limited to brochures, newsletters, presentations, websites, social media, and other print and digital media.
- Use in educational materials and presentations.
I understand that these materials may be used in perpetuity.
I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph(s) and/or video(s).
I hereby release, discharge, and agree to hold harmless Intervention Support Service, LLC, its employees, agents, and assigns, from any and all claims, demands, or causes of action that I may have now or in the future arising out of or in connection with the use of the photographs and/or video.
This release shall be binding upon me, my heirs, legal representatives, and assigns.
(if participant is under 18 years old, parent or guardian consent required)