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Community Breathwork Agreement 

Center for Medicinal Mindfulness

v7 2022

Please read the following information. If you have any questions, please check with one of the facilitators. Community Breathwork is intended as a personal growth experience and should not be looked upon as a substitute for psychotherapy. Community Breathwork can involve dramatic experiences accompanied by strong emotional and physical release. 

This practice is not appropriate for pregnant women, or for persons with cardiovascular or heart problems, severe hypertension, severe mental illness, recent surgery or fractures, glaucoma, retinal detachment, osteoporosis, acute infectious illness, or epilepsy.  Persons with medical or mental health contraindications, under medical supervision, with a history of mental health disorders or using prescription medications should consult their doctor prior to participating in a Community Breathwork event.  If you have asthma, please bring your inhaler to the event.

 

I HAVE READ THE FOLLOWING STATEMENTS 

I certify that I am in good physical and mental health meaning that I am psychologically and physically capable of participating in Community Breathwork and do not have any medical or mental health contraindications that would prevent me from safely participating in a Community Breathwork event.

I understand and agree that my participation in Community Breathwork is voluntary and at my own risk.

I understand that Community Breathwork practice is intended as a personal growth experience and is not a substitute for psychotherapy or medical treatment.

I understand that Community Breathwork could involve dramatic experiences, be accompanied by strong emotional and physical release and/or cause physical, emotional and mental stress or anxiety.

I understand that the use or possession of illicit or controlled substances is expressly prohibited before, during or immediately after a Community Breathwork Event.

I agree to indemnify and hold harmless MMClinic LLC & MMTraining LLC (hereinafter collectively referred to the Center for Medicinal Mindfulness or MM) and each of their agents, contractors, affiliates, representatives, and partners from and against any and all injuries, losses, damages, reasonable costs (including reasonable attorneys’ fees and expenses), liabilities or expenses arising from or caused by my participation in Community Breathwork. 

 

Community Breathwork Participant Contract Release, Waiver, and Indemnity of Liability Agreement

This form must be completed by you (the “Breathwork Participant” or “Participant”) at your first Community Breathwork event (“Program”) and then once every calendar year thereafter. 

This is a legally binding agreement (“Agreement”) between you the Breathwork Participant and MMClinic LLC & MMTraining LLC, its officers, agents, principals, employees, and volunteers (hereinafter collectively referred to as “MM”). Please read the terms of this Agreement carefully. You must read, agree to and sign this Agreement before participating in any MM Program. Do not sign this agreement if you do not agree or do not understand its terms written below.

MM reserves the right to decline any individual interested in participating in any Program at any time and for any reason MM may deem appropriate.

In consideration of being admitted to the Program and permitted to participate in the activities and Community Breathwork I hereby agree as follows:

1. This Agreement is made and entered into voluntarily by you the Breathwork Participant. You agree to take full responsibility for your participation in the Program and all outcomes resulting from such participation. You agree to ask for additional support as needed from MM. You accept the inherent risks of the Program and acknowledge that your interest in this type of adventure and your desire for experiences beyond the normal safety and comfort of your ordinary day-to-day experiences is in part the reason for your participation in the Program.  

2. Breathwork Participant has reviewed the medical contraindications outlined above and certifies that he/she does not have any medical or physical conditions which would impair or affect his/her ability to engage in any activities or which would cause any risk of harm to Breathwork Participant, other participants and/or MM or otherwise endanger Participant’s health while attending a Community Breathwork Program. Participant further agrees that it is Participant’s responsibility to maintain the accuracy and contemporaneousness of all relevant medical information. MM will assume that Participant’s medical statement is correct until Participant files an updated or has corrected the information. The medical information is fully incorporated by reference within this agreement. 

3. Participant is aware that certain activities he/she may engage in during the Program are physically, emotionally and mentally stressful. Participant agrees to assume full responsibility for his/her own physical, emotional and mental health and hold harmless MM from any physical, emotional and/or mental damage that may be attributed to Community Breathwork. Participant further holds harmless MM from any and all loss, liability, injury, damage or cost which may arise out of or in connection with participation in the Program. 

4. Participant understands and agrees that he/she is attending the Program at the discretion of MM and can be dismissed from the Program at any time without being informed of the reason for dismissal. 

5. Participant waives, releases and discharges any and all claims, rights and/or causes of action which he/she now have or which may arise out of or in connection with participation in the Program as well as which may arise out of or in connection with Participant’s attendance and/or participation in the activities associated with the Program. Therefore, under no circumstance will Participant prosecute or present any claim for personal injury, property damage or any other cause of action against MM and each of their agents, contractors, affiliates, representatives, and partners.

6. This agreement is binding on Participant’s heirs, assignees, dependents, personal representatives and estate. 

7. No oral representations, statements or inducements have been made to Participant to cause them to enter into this agreement. 

8. Breathwork Participant agrees that any dispute or controversy arising under or relating to this Agreement or the Program shall be governed by and construed in accordance with the laws of the State of Colorado excluding its conflict of law rules. You agree that any cause of action arising out of or related to this Agreement must commence within one (1) year after the cause of action arose; otherwise, such cause of action is permanently barred. You irrevocably consent to the exclusive personal jurisdiction of the Colorado State Court located in Boulder, Colorado for any suit or action arising from or related to this Agreement and waive any right you may have to object to the venue of such courts.  At the choosing of MM in its sole discretion any claim or controversy that arises out of or relates to this Agreement, or the breach of it, may be settled by arbitration in accordance with the rules of the American Arbitration Association.  Such arbitration shall be binding upon the parties and judgment upon the award rendered in arbitration may be entered in any court with jurisdiction. Should MM be successful in bringing an action to enforce the terms hereof or successful in defending itself from a suit brought by Participant, MM shall recover all costs and expenses incurred in such action, including reasonable attorneys’ fees. 

9. Should any provision of this Agreement be held invalid or illegal, such illegality shall not invalidate the remainder of this Agreement. In that event, this Agreement shall be construed as if it did not contain the invalid or illegal part, and the rights and obligations of the parties shall be construed and enforced accordingly. 

I agree to the above terms and conditions of this Agreement, and that these terms and conditions will govern my participation in Community Breathwork. I understand that this Agreement contains a limitation of liability provision, which I have read, understood and consented to in a sober state of mind.

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*
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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.
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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