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ATLAS BALANCING WAIVER/RELEASE FORM


Atlas Balancing is not an alternative to a medical treatment or diagnosis. The Atlas Balancer is not a doctor or a medical practitioner and it is not the intention to replace any of these functions. Hence, you must not interrupt or stop any ongoing medical treatments, and any necessary treatments must not be postponed respectively.

Atlas Balancing is not a practice of medical science/medicine. No diseases, no symptoms of diseases, no disorders and no sicknesses are treated. This method is not a chiropractic or osteopathic manipulation. No promises of cure have been made. It is my sole responsibility and my free decision to continue or to stop my session(s) of Atlas Balancing with Debbie Loshbough. The agreement/refusal of the course of the session(s) is solely my own responsibility.

I or my representative(s) agree to fully release and hold harmless Debbie Loshbough, Carina Leuenberger, from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).

Disclaimer:

Atlas Balancing does not replace medical treatment, nor does it claim to heal a person in any form. Its sole function is to support the self-healing capacities of the client, physically and mentally, as well as working on the energetic levels of consciousness.


Health insurance does not compensate for this type of work.

I give permission for Debbie Loshbough, Carina Leuenberger and/or HH Collective Wellness, to freely use my testimonial (should I provide one to her) on websites and promotional materials.



First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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