Your information
Full legal name
Name as it should print on your certificate
Credentials as they should print on your certificate
License number
Other state licenses (optional)
Clinic or employer (optional)
Participation agreement and release
Please read each section. The checkboxes and your signature below are required to participate.
1. What the course involves
This is a two-day, in-person continuing education course. Most of the time is hands-on laboratory work: participants work in pairs, and each person scans and is scanned by other participants on the shoulder, elbow, wrist and hand, hip and thigh, knee, and ankle and foot. Scanning uses diagnostic ultrasound at standard musculoskeletal imaging settings, coupling gel, and transducers cleaned between uses. The course also involves long periods of standing and repeated positioning at scanning tables.
I understand what the course involves.
2. Serving as a scanning model
Being scanned means exposing the region being studied. Wear or bring clothing that allows access to each region (a tank top or loose short-sleeve shirt and athletic shorts). Draping is available for the hip and thigh.
You may decline to be scanned on any region, or stop being scanned at any time, without giving a reason. Declining to serve as a model does not affect your certificate. You still complete each laboratory as the person scanning.
I agree to be scanned by other participants and the instructor during laboratory sessions, subject to my right to decline any region at any time.
3. This is not a medical examination
Scans performed in this course are educational. They are not diagnostic examinations, no one reviews them to diagnose you, and no provider–patient relationship is created between you and the instructor or any other participant. No report is issued and no clinical images of you are kept.
A scan may occasionally show something unexpected. If that happens, the instructor may tell you privately and suggest that you follow up with your own healthcare provider. What you do with that information is your decision. A normal-looking scan in this course does not mean a region is free of injury or disease.
I understand that course scans are educational only, are not a medical examination, and may occasionally reveal an incidental finding.
4. Health and safety
You are responsible for deciding whether you can safely take part, and for telling the instructor privately about anything that affects how you should be scanned or positioned (for example, a recent surgery, an open wound or skin condition, or a gel or latex sensitivity). Tell the instructor right away if you feel unwell or are injured during the course.
If you need emergency care, I authorize the instructor and host facility staff to call emergency medical services and to share my emergency contact information with them.
I accept responsibility for my own participation and authorize emergency care if needed.
5. Assumption of risk and release
I understand that participating in hands-on laboratory instruction carries risks, including muscle strain or fatigue from positioning and prolonged standing, skin irritation from gel or cleaning agents, slips on gel, and incidental findings as described above. I voluntarily assume these risks.
To the fullest extent permitted by law, I release and agree not to bring claims against Ethan D. Brinkmann, PT, DPT, doing business as Enigma DPT and Ultrasonography, and Myokinetix, the host facility, including their owners, employees and agents, for any injury, loss or damage arising from my participation in the course, except for injury, loss or damage caused by their gross negligence or willful misconduct.
I have read and agree to the assumption of risk and release.
6. Recording and photos
The instructor records audio of the lectures and demonstrations for use in future course material. Participant questions and discussion may be picked up in the background. Participants may not photograph or record another participant without that person's permission.
Separately, I may take photos or short video during laboratories for course promotion and teaching. Choose below. Saying no does not affect your participation.
I understand that instructional audio is recorded. May I use photos or video that include you for course promotion and teaching?
7. Attendance and certificate
The NJ Board requires that you sign in on arrival and sign out on departure each day, on the paper attendance sheet at the registration table. Certificates of completion are issued only to participants who attend both full days. Your name and license number are kept with the course attendance records, which I retain and provide to the Board on request.
I understand the attendance requirement and how my information is used.
