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Fire Woman Events 

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 for Somatic Release Breathwork™

 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.


Contraindications for Cacao

Cacao contains natural stimulants like theobromine and caffeine, which can affect the cardiovascular system. It is not recommended for those who:

  • Are pregnant or breastfeeding
  • Take prescription antidepressants (MAO inhibitors)
  • Have heart conditions or high blood pressure
  • Use hypertension medication

Herbal tea will be available as an alternative for those with these contraindications. 


Contraindications for Sound Therapy

Sound therapy, including gong sound therapy, may not be suitable for:

  • Those with hearing aids, tinnitus, or other hearing sensitivities
  • Pregnant women, due to deep vibrations
  • Individuals with pacemakers or other implanted medical devices
  • Those on medications affecting the nervous system, including antidepressants


Release

 I hereby release and hold harmless Fire Woman Events 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*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
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*
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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