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Health Declaration & Liability Waiver

Please fill out the following form
to confirm your attendance.

Have you been hospitalized in the last 12 months?
Are you suffering from a medical condition, illness, or injury?

Liability Release:

I, the participant, have voluntarily enrolled in this Breathwork activity. I understand that I am under no obligation of any kind to participate in this Breathwork activity and I voluntarily enter into this Waiver and Release of Liability. I agree to be open minded to Facilitator’s methods and partake in Activities and services as proposed and instructed. I understand that Facilitator has made no guarantees as to the outcome of Activities, and that information and testimonials presented before, during, or after Activities do not constitute a warranty of specific outcomes.

I understand that Breathwork is designed to enhance quality of life and support holistic wellbeing, and is not intended to constitute medical advice or any substitution for medical care. I understand that Breathwork is not intended to be relied upon for diagnosis or treatment in relation to any health problem, and services of the Facilitator do not replace the care of licensed or medical professionals. I understand that this Breathwork activity will involve strong connected breathing and may include guided mediation. I understand that Breathwork can involve dramatic experiences accompanied by strong emotional and physical responses. I understand that I may find these experiences physically, emotionally and/or mentally stressful. I understand that breathwork is not safe under certain medical conditions and not advised for persons with a history of cardiovascular disease or prior heart attack, high blood pressure, use of prescription blood thinners such as Coumadin, epilepsy or seizures, glaucoma, osteoporosis, severe asthma, bipolar disorder, schizophrenia, dissociative disorders, and during pregnancy.

I hereby affirm that I am in good health and able to participate in this activity. I do not have any physical or mental conditions which would impair my ability to engage in this activity or which would otherwise endanger my health during this Breathwork activity, or which would cause any risk of harm to myself or other participants. I understand that this activity is not medically supervised. I have hereby been advised that I should talk to my physician and/or psychotherapist if I have any questions about my physical or mental ability to safely participate in this Breathwork activity. If I have chosen not to obtain a physicians consent prior to my participation in Breathwork, I hereby agree that I am doing so solely at my own risk.

 

I understand that it is my sole responsibility to participate in activities that are appropriate for the current status of my health and to modify this Breathwork activity to accommodate my own needs or limitations. If I have any questions or concerns about whether or not a particular activity is appropriate to my current health status, I understand it is my responsibility to ask my doctor before I participate in such activity.

I understand that unless otherwise explicitly stated, Activities offered will not be recorded or shared, and no photograph(s), video(s), or audio(s) will be taken for marketing purposes or otherwise. I understand that information shared with the Facilitator is privileged communication and strong ethical standards of confidentiality are maintained. I understand that in voluntarily revealing personal information in group Activities, rights of privacy and confidentiality are waived and cannot be guaranteed. I also understand that confidentiality may be waived, without consent, if there is imminent danger to yourself or others, or there is occurrence of child, elder, or dependent adult abuse or neglect.

I agree to indemnify and hold harmless Benjamin Timby from and against any and all claims and expenses, including attorneys fees, arising out of my participation in this Breathwork activity. I accept any and all risks, foreseeable or non-foreseeable, arising from such transaction. I agree that Facilitator will not be held liable for any damages of any kind resulting or arising from including but not limited to; direct, indirect, incidental, special, negligent, consequential, or exemplary damages happening from participation in Activities or use of materials provided. In consideration of my participation in this Breathwork activity, I hereby waive and release Benjamin Timby from any and all claims, costs, liability and expense for any injury, loss or damage whether known, anticipated or unanticipated arising from my participation in Breathwork. This Waiver and Release of Liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

I acknowledge that I have thoroughly read this Waiver and Release of Liability in its entirety and fully understand it. By signing this document, I am waiving certain rights and I/or my successors might have to bring legal action or assert a claim against Benjamin Timby.

Thanks for submitting!

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