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Group Breathwork & Hypnosis Waiver

I, (“the Releasor”), understand and acknowledge that the discussions, consultations and A Deep Space session(s) I have, the Releasees: a) are not intended to replace any relationship I have with my medical doctor and/or primary health care provider(s); b) are not intended to constitute medical advice or any substitution for medical care; c) are not intended to be relied on for prescriptions, recommendations, diagnosis or treatment in relation to any health problem or disease; 

I understand that if I am taking any medications or have any medical conditions such as, but not being limited to: schizophrenia, bi-polar, epilepsy, heart conditions, or pregnancy, that I must advise the facilitator/s. I also understand that even though I have been accepted as a participant, I am responsible for any consequence resulting from The A Deep Space Session. I certify that I have consulted a health professional regarding any condition physical, mental or emotional that could interfere with my judgment, or affect my health in any way during or after The A Deep Space Session. I understand and acknowledge that I am responsible for consulting my health care provider or doctor in case I have or suspect to be suffering from a health problem. I understand the stories or testimonials presented before or during the session do not constitute a warranty, guarantee, or prediction regarding my experience during or after the session. The A Deep Space facilitators make no warranty, guarantee, or prediction that I will experience any particular state of awareness or consciousness during or after The Session, nor does it make any representation that I will experience any particular outcome on an issue. In the instance of a group process I may voluntarily reveal personal information, in doing so I understand that and hereby waive my rights of privacy and confidentiality. I further understand that my participation in The Session is not intended to create nor does it establish a client-practitioner relationship or any other type of therapeutic or professional relationship between me and A Deep Space facilitators. I understand that The A Deep Space Session could include a physical touch designed to support me in my path, and that I have the right to refuse this contact by using the word “stop”. I understand and acknowledge that by participating in The A Deep Space, I do it at my own risk. It is with this understanding that I voluntarily sign this waiver. Since the Session is experiential and the extent of the Session’s risks and benefits are not fully known, I agree to assume and accept full complete responsibility for any known and unknown risks associated with my participation in the Session, including any physical injury, psychological or emotional effects, death, loss, or property damage. I agree and understand the Session may be filmed, photographed and/or recorded and that the A Deep Space facilitators shall have all rights in and to such film, photographs and/or recording, including the copyright therein. The copyright shall include, but not be limited to, the right to use, re-use, publish, and re-publish and otherwise reproduce, modify, and display any such film, photograph and/or recording for educational and promotional purposes, including without limitation, audiotapes, audio CDs, DVDs, websites, video, or film or any other form of recorded images. I grant the the A Deep Space facilitators and Lindsey Harris the right, without compensation to myself, to film, photograph and/or record you while participating in the Session and I waive any right which I now have or may have hereafter in any such film, photograph and/or recording. I agree to not record by audio, video, photographic or any other means, any portion of the Session. In my personal name, that of my heirs and assignees, I exonerate and totally and indefinitely release the relinquishers of any suit, complaint, declaration, damage, cost and / or expense of any kind (that any such prosecution, complaint, declaration, damage, cost and / or expense is caused by the passive or active negligence of the Releasees or otherwise) in connection resulting from any discussion, consultation and / or Session I had. I have read and understand all above statements.


First Releasor/ Client Name

First Name*

Middle Name

Last Name*
First Releasor/ Client Date of Birth*
First Releasor/ Client Information
I, The Releasor/ Client/ Class Attendee, understand that if I am taking any medications or have any medical conditions such as, but not being limited to: schizophrenia, bi-polar, epilepsy, heart conditions, or pregnancy, that I must advise the facilitator/s*
No
Yes

Medications / Health Conditions (leave blank if none)
First Releasor/ Client Signature*
Second Releasor/ Client Name

First Name*

Middle Name

Last Name*
Second Releasor/ Client Date of Birth*
Second Releasor/ Client Information
I, The Releasor/ Client/ Class Attendee, understand that if I am taking any medications or have any medical conditions such as, but not being limited to: schizophrenia, bi-polar, epilepsy, heart conditions, or pregnancy, that I must advise the facilitator/s*
No
Yes

Medications / Health Conditions (leave blank if none)
Third Releasor/ Client Name

First Name*

Middle Name

Last Name*
Third Releasor/ Client Date of Birth*
Third Releasor/ Client Information
I, The Releasor/ Client/ Class Attendee, understand that if I am taking any medications or have any medical conditions such as, but not being limited to: schizophrenia, bi-polar, epilepsy, heart conditions, or pregnancy, that I must advise the facilitator/s*
No
Yes

Medications / Health Conditions (leave blank if none)
Fourth Releasor/ Client Name

First Name*

Middle Name

Last Name*
Fourth Releasor/ Client Date of Birth*
Fourth Releasor/ Client Information
I, The Releasor/ Client/ Class Attendee, understand that if I am taking any medications or have any medical conditions such as, but not being limited to: schizophrenia, bi-polar, epilepsy, heart conditions, or pregnancy, that I must advise the facilitator/s*
No
Yes

Medications / Health Conditions (leave blank if none)
Fifth Releasor/ Client Name

First Name*

Middle Name

Last Name*
Fifth Releasor/ Client Date of Birth*
Fifth Releasor/ Client Information
I, The Releasor/ Client/ Class Attendee, understand that if I am taking any medications or have any medical conditions such as, but not being limited to: schizophrenia, bi-polar, epilepsy, heart conditions, or pregnancy, that I must advise the facilitator/s*
No
Yes

Medications / Health Conditions (leave blank if none)
Sixth Releasor/ Client Name

First Name*

Middle Name

Last Name*
Sixth Releasor/ Client Date of Birth*
Sixth Releasor/ Client Information
I, The Releasor/ Client/ Class Attendee, understand that if I am taking any medications or have any medical conditions such as, but not being limited to: schizophrenia, bi-polar, epilepsy, heart conditions, or pregnancy, that I must advise the facilitator/s*
No
Yes

Medications / Health Conditions (leave blank if none)
Seventh Releasor/ Client Name

First Name*

Middle Name

Last Name*
Seventh Releasor/ Client Date of Birth*
Seventh Releasor/ Client Information
I, The Releasor/ Client/ Class Attendee, understand that if I am taking any medications or have any medical conditions such as, but not being limited to: schizophrenia, bi-polar, epilepsy, heart conditions, or pregnancy, that I must advise the facilitator/s*
No
Yes

Medications / Health Conditions (leave blank if none)
Eighth Releasor/ Client Name

First Name*

Middle Name

Last Name*
Eighth Releasor/ Client Date of Birth*
Eighth Releasor/ Client Information
I, The Releasor/ Client/ Class Attendee, understand that if I am taking any medications or have any medical conditions such as, but not being limited to: schizophrenia, bi-polar, epilepsy, heart conditions, or pregnancy, that I must advise the facilitator/s*
No
Yes

Medications / Health Conditions (leave blank if none)
Ninth Releasor/ Client Name

First Name*

Middle Name

Last Name*
Ninth Releasor/ Client Date of Birth*
Ninth Releasor/ Client Information
I, The Releasor/ Client/ Class Attendee, understand that if I am taking any medications or have any medical conditions such as, but not being limited to: schizophrenia, bi-polar, epilepsy, heart conditions, or pregnancy, that I must advise the facilitator/s*
No
Yes

Medications / Health Conditions (leave blank if none)
Tenth Releasor/ Client Name

First Name*

Middle Name

Last Name*
Tenth Releasor/ Client Date of Birth*
Tenth Releasor/ Client Information
I, The Releasor/ Client/ Class Attendee, understand that if I am taking any medications or have any medical conditions such as, but not being limited to: schizophrenia, bi-polar, epilepsy, heart conditions, or pregnancy, that I must advise the facilitator/s*
No
Yes

Medications / Health Conditions (leave blank if none)
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*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
I, The Releasor/ Client/ Class Attendee, understand that if I am taking any medications or have any medical conditions such as, but not being limited to: schizophrenia, bi-polar, epilepsy, heart conditions, or pregnancy, that I must advise the facilitator/s*
No
Yes

Medications / Health Conditions (leave blank if none)
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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