Self-Management of Insomnia

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Password
(Should be between 4 and 20 symbols long and not contain your username):

Confirm Password:

EMail:

Gender:
- Please Select One: Male Female

Year of Birth:
- Please Select One: < 1940 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 > 2000

City closest to the place you live:

I acknowledge that I may experience increased sleepiness during the program. I understand that I should not operate a motor vehicle, machinery or equipment, make important decisions or otherwise conduct activities where alertness is important when in a tired or sleepy state. I know that doing so is hazardous and could lead to loss including injury or death and therefore I will not operate a motor vehicle, machinery or equipment make important decisions or otherwise conduct activities where alertness is important when in a tired or sleepy state. I assume all risks associated with this program, will be solely responsible for any injury, loss or damage that I might sustain while participating in this program and if I am uncertain, I will not commence this program without first consulting my physician.

Having read this waiver and knowing these facts and in consideration of my commencing this program,
I, (fill in your real name) for myself and anyone entitled to act on my behalf including my heirs, executors, administrators and representatives, hereby waive and release and forever discharge the University of Toronto, The Sleep and Alertness Clinic and its umbrella organizations, its employees, volunteers, independent contractors, officers and director, and their representatives and successors from all claims or liabilities of any kind and for any cause whatsoever arising out of my participation in this Program. I sign this waiver and release, freely, voluntarily and understanding its meaning and significance. I confirm that I am at least 18 years of age.

Please sign below to accept the above conditions, waiver and release. In any event, your use of any module of this program shall be deemed acceptance of the above waiver and release. If you do not agree, do not use any of this program.