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Fire Woman LLC 

Breathwork Waiver 

I acknowledge that Somatic Release Breathwork™ is a deep and powerful process. I have notified the practitioners of any physical injuries, mental or psychological conditions I have. I engage in this experience willingly and take full responsibility for my own physical, mental and emotional experiences during and after the session.

 

Contraindications

 

Somatic Release Breathwork™ is intended as a personal growth experience and should not be looked upon as a substitute for psychotherapy. It is not appropriate for pregnant women, for persons with cardiovascular problems, including angina or heart attack, high blood pressure, glaucoma, retinal detachment, osteoporosis, history of seizures, stroke, major psychiatric conditions, recent surgery, acute infectious illness or epilepsy. If you have any doubt about whether you should participate, please consult with your primary care physician. Persons with asthma should bring their inhaler and consult with their primary care physician.

 

Release

 

I hereby release and hold harmless Fire Woman Healing LLC from any and all results that arise during or from the Somatic Release Breath-work. I waive all rights under law regarding the same. I or my representative(s) agree to full release and hold Fire Woman Healing LLC  harmless from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).

 

Attestation of good health

 

I hereby confirm that I have read and understood the above information and attest that my general health is good to participate . 

First Participant's Name

First Name*

Middle Name

Last Name*

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

Email*

Confirm Email*
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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*

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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