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Re|Connect Mind Body, PMA

Liability Waiver


1.     In consideration of my participation in therapies with Re|Connect Mind Body, PMA, I hereby release, discharge and covenant to not sue Re|Connect Mind Body, PMA. located at 5735 E. McKellips Rd. Ste. 110 Mesa, AZ 85215, its directors, officers, employees, teachers, coaches and agents for any and all claims, demands, debts, contracts, expenses, cause of action, lawsuits, damages, and liabilities, of every kind of nature, whether know or unknown, in law or equity, that I ever had may have, arising from or in any way related to my participation in any of the events, activities, treatments conducted by, on the premises, of, or for the benefit of Re|Connect Mind Body, PMA. provided that this waive of liability does not apply to any acts of gross negligence, or intentional, willful or wanton misconduct.

2.     I understand that the activities/treatments, in which I will participate, are inherently dangerous and may cause serious or grievous injuries, including bodily injury, damage to personal property and/or death. On behalf of myself, my heirs, assigns, administrators, executors and next of kin, I waive all claims of damage, injuries and death sustained to me or my property, that I may have against the aforementioned release party to such activities/treatments, including claims in tort, contract, equity or otherwise. 

3.     I acknowledge, agree, and represent that I understand the nature of Re|Connect Mind Body, PMA. Re|Connect Mind Body, PMA. offers a variety of therapy treatments for use by clients solely at their own risk. I understand and acknowledge that Re|Connect Mind Body, PMA. makes no claims as to the safety, results or the appropriateness of any program, activity and/or treatment for any individual.

4.     I understand that before participating in any exercise and/or a health-related program or any Re|Connect Mind Body, PMA. treatment that I should consult my physician and in the event my health condition changes while I am using Re|Connect Mind Body, PMA. facilities/treatments, I agree to consult with my physician prior to resuming any and all activities/treatments at Re|Connect Mind Body, PMA. I understand and agree that all suggestions and/or instruction made by Re|Connect Mind Body, PMA. staff concerning exercise, nutrition or any Re|Connect Mind Body, PMA. treatment are neither diagnostic nor prescriptive an that I should verify the same with my physician and I will evaluate such instructions and/or suggestions independently. Notwithstanding the foregoing, I warrant and represent that I am in good health and that I am able to use Re|Connect Mind Body, PMA. facilities and participate in Re|Connect Mind Body, PMA. treatments/programs, without limitation.

5.     I further acknowledge and agree that use of Re|Connect Mind Body, PMA. facilities, participation in the Re|Connect Mind Body, PMA. programs and Re|Connect Mind Body, PMA. treatments may involve a high degree of risk and at times may be hazardous to my health.

6.  By this Waiver, I am made aware that Re|Connect Mind Body, PMA. may or may not record my likeness and/or voice on a video, photographic, or digital medium for use on social media, website, or other promotional material. Please authorize or decline consent in "Media Release" section below.

7.   By this Waiver, I assume any risk, and take full responsibility and waive and of personal injury; death, damage, or loss of personal property, associated with Re|Connect Mind Body, PMA. and/or Agents of Re|Connect Mind Body, PMA. including but not limited to using the facility and its equipment in any manner, form or fashion, and participating and/or engaging in any meditative classes, cold therapy, cold water immersion therapy, red light therapy, sauna therapy and aromatherapy.

8.     Any health concerns we at Re|Connect Mind Body, PMA. should be informed about before beginning your experience with us. (Heart Condition, pregnant, Diabetic, Vascular damage, etc.) Please fill out "Health Concerns" section below if so.

9.     By this Waiver, I am made aware that I may not use, or reproduce, or retransmit or allow anyone else to use, or reproduce, or retransmit any Re|Connect Mind Body, PMA intellectual property, material or trademarks or assist anyone in doing so without express, written consent, and authorization. I accept I must obtain permission from the company’s intellectual property rights owner and consult a legal professional for guidance in proceeding accordingly to obtain authorization. I understand that my unauthorized use of intellectual property can infringe upon the legal rights of the owner and may lead to legal actions and consequences. Please confirm in "Terms & Conditions" section below.

10.    By this waiver, I am made aware that Re|Connect Mind Body, PMA uses SMS for 1:1 communications with the goal of providing the best possible customer service and possibly the receipt of automated messages. I understand consent is not a condition of purchase and that Re|Connect Mind Body, PMA will not sell my information. I will have the option to reply STOP to opt-out of text messaging if I prefer. Please confirm in "Communications" section below.

Date: April 11, 2025









First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Email Address

Email *
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Email Address

Email *
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Email Address

Email *
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Email Address

Email *
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Email Address

Email *
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Email Address

Email *
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Email Address

Email *
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Email Address

Email *
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Email Address

Email *
Tenth Participant's Name

First Name*

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

Email *
Parent or Guardian's Email Address

Email*
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Participant's Gender

Please enter below (Example: Male, Female, Non-Binary, etc.)


Gender: *
Health Concerns
Any health concerns you would like us to be aware of? *
Yes
No

If 'Yes', please explain below:

Media Release
Do you authorize Re|Connect Mind Body, PMA to record your likeness and/or voice on a video, photographic, or digital medium to be used for social media, website, or other promotional material? *
Yes
No
Communications

By checking the box below, I give my consent that Re|Connect Mind Body, PMA may contact me at the telephone number I provided via SMS for 1:1 communications with the goal of providing the best possible customer service and possibly receipt of automated messages. Consent is not a condition of purchase. Re|Connect Mind Body, PMA will not sell your information.

Re|Connect Mind Body PMA may reach out to you with communications including, but not limited to, session follow ups, bookings/rescheduling, Breathwork & Sound class invitations, billing, etc. You may utilize SMS to inquire on scheduling, membership changes/upgrades/cancellation, general questions, etc. You will have the option to reply STOP to opt-out of text messaging, but please note this will prevent you from communicating with Re|Connect Mind Body, PMA via text messaging and you will have to opt in again to resume communications.

Confirmation: *
Yes
Terms & Conditions

The Re|Connect Way, motto of "You are the cause. You are the cure.", logo, documentation, etc. are the intellectual property of Re|Connect Mind Body, PMA. You may not use, or reproduce or retransmit or allow anyone else to use, or reproduce, or retransmit any of our intellectual property, material or trademarks or assist anyone in doing so without express, written consent and authorization.

To use The Re|Connect Way and other intellectual property owned by Re|Connect Mind Body, PMA, you must obtain permission from the company’s intellectual property rights holder and consult a legal professional for guidance in proceeding accordingly to obtain authorization.

Failure to adhere to these terms and conditions and your unauthorized use of Re|Connect Mind Body, PMA intellectual property can infringe upon the legal rights of the holder and may lead to legal actions and consequences.

My Selection Below Confirms I Agree, Accept, and Understand These Terms & Conditions:*
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*
I certify that I am 18 years of age or older
Parent or Guardian's Email Address

Email *
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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