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Breathwork Waiver and Release of Liability

I 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 understand that Breathwork is a personal growth experience designed to enhance the quality of life, and is not a substitute for psychotherapy. I understand that this Breathwork activity will involve strong connected breathing and may include guided meditation.  I understand that Breathwork can involve dramatic experiences accompanied by strong emotional and physical responses.  I understand that I may find Breathwork physically, emotionally, and/or mentally stressful. 

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 Breathwork 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 agree to indemnify and hold harmless Charles Robinson and Kai Chi Do Inc. and their respective directors, officers, employees and agents from and against any and all claims and expenses, including attorneys fees, arising out of my participation in this Breathwork activity.

In consideration of my participation in this Breathwork activity, I hereby waive and release Charles Robinson and Kai Chi Do Inc. 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 I and/or my successors might have to bring legal action or assert a claim against Charles Robinson and/or Kai Chi Do Inc.

First Participant's Name

First Name*

Middle Name

Last Name*

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
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Parent or Guardian's Email Address

Email*

Confirm Email*
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The undersigned parent and/or guardian does hereby represent that he/she is, in fact, acting in such capacity, hereby consents to his/her child or ward's participation in Breathwork, and has agreed individually and on behalf of the child or ward, to the terms of the Waiver and Release of Liability set forth above. The undersigned parent or guardian further agrees to hold harmless and indemnify each and all parties referred to above from any and all claims, costs, liability and expense for any injury, loss or damage whether known, anticipated or unanticipated arising from the participation of the child or ward in this Breathwork activity. The undersigned parent or guardian hereby represents that they are signing this Waiver and Release of Liability on behalf of the minor and any or all parents or guardians of the child.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
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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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