BREATHWORK LIABILITY WAIVER & RELEASE FORM

TERMS AND CONDITIONS

Please read in full and answer the intake form below the page prior our first call.

(1) The client(s) agree to the following terms and conditions:
1.1 The client is seeking breathwork services to be provided by Caroline Clarke.
1.2 The client agrees to sign this Informed Consent and Assumption of Risk and Release of Liability.
1.3 This session is not recommended and is not safe under certain medical conditions. I, the client agree to inform Caroline Clarke of any medications I am currently taking, and medical conditions or physical limitations I have prior to the session. I will disclose all conditions, medical or otherwise, that may affect my ability to participate in this breathwork session.
This includes present or near past experiences of experiencing severe mental illness, neurological conditions, heart conditions, history of blood clots, currently experiencing spiritual emergence/crisis, epilepsy and seizures, detached retina and other ocular issues, heart conditions/attacks, high blood pressure, pregnancy, recent physical injuries, fractures, and surgeries.
I confirm that I am not pregnant, nor do I have severe asthma, heart disease, diabetes, a mental illness, epilepsy/history of seizures and/or acute physical injuries or any other contraindications of breathwork. In the case of any of these conditions I understand participation will be terminated and I will not be allowed to participate in the session as a precaution to my health and wellbeing.
1.4 I understand and acknowledge that the facilitator does not diagnose medical or psychological conditions, reform medical treatment, prescribe substances, provide counselling or interfere with the treatment of licensed medical or psychological professionals.
1.5 I understand If I experience any unusual pain or discomfort, I will listen to my body and stop the session, and clearly communicate this to the facilitator and ask for guidance from the facilitator. I assume full responsibility for all damages, which may incur through participation in this session.
1.6 I understand taking alcohol or drugs prior to, or during this session will result in me not being able to participate in the session. I agree that I will not be under the influence of drugs or alcohol whilst attending this session.
1.7 I confirm that I, alone, am responsible for deciding whether to participate in the breathwork session and that I participate fully at my own risk.
1.8 I understand that this session includes breathwork and trauma release which is made up of physical movement, breathing, meditation, release of emotions, touch, body work and music. I understand that each of these will be included in the session.
(2) I the client certify that I am of adequate physical condition to participate in physical exercise. I certify that I am aware of the nature of this event and assume the full risk of participating in this event.
(3) I consent that I am in good physical health and of sound mind, and do not suffer from any condition that would hinder my participation in any activity by Caroline Clarke. These
activities include but are not limited to, physical movement, breath, meditation, release of emotions, touch, bodywork, and music. I understand that my participation in all offerings held by Caroline Clarke.
(4) I hereby release my image should photos be taken in group activities that may later appear on future media, for websites, social, or any press purposes. I give my permission to use my likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, that I send to Caroline Clarke and or to their social media. By completing this release, responding to this email, showing up for the session with Caroline Clarke , I agree to these terms.

BY SIGNING BELOW & TURNING UP TO THE SESSION, I, THE CLIENT ACKNOWLEDGE HAVING READ AND UNDERSTOOD THIS CONTRACT AND THAT I, THE CLIENT ARE SATISFIED WITH THE TERMS AND CONDITIONS CONTAINED IN THIS CONTRACT. THE CLIENT SHOULD NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME YOU SIGN IT.

ACKNOWLEDGMENT

I AM IN GOOD PHYSICAL AND MENTAL HEALTH AND DO NOT SUFFER FROM ANY MEDICAL OR PHYSICAL CONDITIONS THAT COULD IN DANGER MYSELF OR OTHERS AS A RESULT OF MY PARTICIPATION IN THE ACTIVITIES, AND I ACCEPT TO PARTICIPATE IN THE ACTIVITIES FREELY.

I acknowledge that I have read and completely understand the terms of the release, that I am legally of sound mind, and voluntarily agree to the terms and conditions stated above.