New Directions Waiver And Liability Form Page 2

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Sande Rutstein, OTR/L
Pediatric Occupational Therapist
1522 W. Branch Street
Arroyo Grande, CA 93420
srutstein@sbcglobal.net
P: 805.474.6811 / F: 805.528.5069
I acknowledge that I have read the three paragraphs above, and I have been fully and completely advised of the
potential dangers incidental to engaging in the physical activities provided and that I am fully aware of the legal
consequences of signing this instrument.
Signature of Parent /Guardian : ___________________________
Date: ______________________

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