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Medical Questionnaire and Liability Waiver

I declare that I understand that my participation, direct or indirect, in this Limitless - Soul, Body, Mind event does not entitle me to any legal rights or action as a result of any accident or incident that should happen during such event. Furthermore, I understand that breathwork and any type or form of immersion in cold water is an inherently dangerous activity. I also understand that my participation in this event does not entitle me to any kind of compensation or remuneration and that by signing this document I testify that I will not under any circumstance, proceed legally against any of the members of Limitless - Soul, Body, Mind as an organisation and/or my instructor/s.

Please read each question carefully and check YES or NO. If you answer YES to any of the questions please discuss the condition with Limitless - Soul, Body, Mind prior to attending the event.

Failure to address any “YES” answered conditions prior to engaging in breathwork and cold immersion activities may endanger your health as well as the safety of other course participants.

Note: A positive answer will not necessarily exclude you from participating in a Limitless - Soul, Body, Mind event but you may need to seek a medical clearance from your doctor.

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*
Check to receive information, news, and discounts by e-mail.
Neurological
E.g. Stroke, brain surgery, severe migraine, significant head injury. *
No
Yes
Psychological
E.g. Anxiety, Panic, depression, ADHD. *
No
Yes
Cardiovascular
E.g. Heart attack, heart surgery, arrhythmias, hypertension. *
No
Yes
Pulmonary
E.g. Pneumothorax, lung disease, emphysema, Pulmonary oedema. *
No
Yes
Ears
E.g. Perforated ear-drums, permanent tubes in ear-drums, hearing loss in one or both ears, ear infections, ear surgery. *
No
Yes
Sinus
E.g. Polyps in the sinus cavities, sinus surgery, sinus infection. *
No
Yes
Asthma
E.g. History of asthma attacks, current use of asthma medication. *
No
Yes
Epilepsy
History of epilepsy. *
No
Yes
Pregnant
Currently pregnant or suspected to be pregnant. *
No
Yes
Additional Cold Water Contraindicators: Check the box if applicable.
Any heart condition
Stroke
Epilepsy
Raynaud's Syndrome
Cold Urticaria
Pregnancy
Anxiety or Panic Disorder
Histamine allergy
Chill Blains
I certify that I have answered the above questionnaire honestly.
Yes
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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