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LIABILITY WAIVER FOR SERVICES UNDER THE GUIDANCE OF BENJAMIN D GETTINGER 

INFORMED CONSENT FOR CLASS, EVENT, PRIVATE SESSION, TRAINING AND/OR RETREAT PARTICIPATION 

I am voluntarily participating in the class, private session, training, event, and/or retreat offered by BENJAMIN D GETTINGER. I understand that I am responsible for monitoring my own condition throughout the duration of the activity and should any unusual symptoms occur, I will cease my participation and inform BENJAMIN D GETTINGER of the symptoms. 

In signing this consent form, I affirm that I have read, accept and understand this form in its entirety and that I understand the nature of the Reiki, dance, yoga and/or meditative activities offered. I know that there may be risks associated with these activities and willingly accept those possibilities. I know that it is my responsibility to ensure my own safety. I take full responsibility for my own health and safety in participating in this class, event, private session, training, and/or retreat and to the extent I deem advisable, will consult a physician before participating in any of the activities. I agree to pay all reasonable costs related to any medical costs I may incur. 

In the event of receiving a Reiki treatment, I understand that Reiki is a stress reduction and relaxation technique. I acknowledge that treatments are only for the purpose of helping me relax and to relieve stress. Reiki practitioners do not diagnose conditions nor do they prescribe substances or perform medical treatment, nor interfere with the treatment of a licensed medical professional. It is recommended that I see a licensed physician, or licensed medical professional for any physical or psychological ailment I may have. I take full responsibility and liability for my experience.

AGREEMENT AND WAIVER / RELEASE OF LIABILITY 

In consideration for being allowed to participate in this activity, which I do freely and voluntarily for my own personal benefit, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors and assigns to: 

1. Waive, release and discharge from any and all liability to BENJAMIN D GETTINGER, his elected and appointed officials, agents and/or volunteers for my death, disability, personal injury, property damage, property theft, actions of any kind which may hereafter accrue to me. 

2. Indemnify and hold harmless BENJAMIN D GETTINGER and his elected and appointed officials from any and all liabilities or claims made by other individuals or entities as a result of or relating to my participation in this activity. 

3. In the case of events, retreats, and trainings, I agree to have my picture taken and grant you permission to use my picture and physical surroundings without restriction in association with the activity in print, projection, digital/internet/web site, video or any future media marketing.  I also consent to the use of my name, my picture, and other material about me for promotional, publicity, or organizational purposes.

Therefore, intending to be bound and as a condition of being allowed to participate in all classes, events, trainings, privates sessions, and/or retreats under the guidance of BENJAMIN D GETTINGER, I have freely signed this waiver on the date indicated.

First Participant's Name
First Name*
Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email
Check to receive information, news, and discounts by e-mail.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Emergency Contact
First Name*
Last 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.


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 Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
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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