Complete this form & then purchase a ticket to sign up for the New Year’s Visioning Breathwork Circle.

IMPORTANT: Please complete this consent and on the next page you will be directed to a payment screen. You will not be able to attend the event without both a signed consent form and payment.

Breathwork Group Disclosure and Liability Agreement

This agreement ("Agreement") is entered into as of the date signed below by and between the participant ("Participant") and the facilitator, Kimberly Massale ("Facilitator") as well as the company Brave Embodiment Counseling (“Company”), of the breathwork group ("Breathwork Group"). By signing this document, the Participant acknowledges and agrees to the terms and conditions outlined herein.

1. Acknowledgment of Breathwork Practice

1.1 Nature of Breathwork: Breathwork is a practice that involves specific breathing techniques aimed at promoting relaxation, self-awareness, and emotional well-being. It is not a substitute for professional medical or psychological treatment.
1.2 Potential Risks: Breathwork may cause physical, emotional, or psychological effects, including but not limited to lightheadedness, tingling sensations, temporary emotional discomfort, or the emergence of suppressed emotions.

2. Participant Representations

2.1 Health Condition: The Participant confirms they are physically and mentally capable of engaging in the Breathwork Group.
2.2 Medical History: The Participant agrees to disclose any medical conditions, including but not limited to cardiovascular issues, epilepsy, respiratory conditions, psychiatric disorders, or pregnancy, that may affect their ability to safely participate.
2.3 Voluntary Participation: Participation in the Breathwork Group is entirely voluntary, and the Participant assumes full responsibility for their engagement.

3. Waiver of Liability

3.1 Assumption of Risk: The Participant understands and accepts the risks associated with breathwork and releases the Facilitator(s) and the Company from liability for any injury, illness, or psychological effects that may arise.
3.2 Limitations of Liability: The Facilitator(s) and the Company shall not be held responsible for any direct or indirect harm resulting from the Participant’s engagement in the Breathwork Group.
3.3 Emergency Situations: In the event of a medical emergency, the Participant consents to necessary medical treatment and assumes financial responsibility for any associated costs.

4. Confidentiality and Privacy

4.1 Group Confidentiality: The Participant agrees to maintain the confidentiality of all personal information shared by other group members.
4.2 Facilitator Responsibility: The Facilitator(s) will ensure reasonable efforts to protect the privacy and confidentiality of the Participant’s information, except where disclosure is required by law or safety concerns.

5. Participant Release and Consent

5.1 Acknowledgment of Understanding: The Participant confirms they have read, understood, and agree to the terms of this Agreement.
5.2 Release of Claims: By signing below, the Participant releases the Facilitator(s) and Company from any claims arising from their participation in the Breathwork Group.

Name

First Name

Last Name

Date

YYYY

I certify that I have read the above disclosure and agree to the terms.

I certify that I have taken medical advice relating to any physical, mental, or emotional condition that may impair my judgement or have any effect on my physical health and am unable to undertake Breathwork.

I understand that if I am taking any strong medications or have any medical conditions then I must discuss with the facilitator before I attend the event. I understand and acknowledge that a breathwork session a) is not intended to replace any relationship with my medical doctor and /or primary health care provider(s) and b) is not intended to constitute medical advice or any substitution for medical care; is not intended to be relied on for prescriptions, recommendations, diagnosis or treatment in relation to any health problem or disease.

I understand that whilst every care is taken, the facilitator and the company will not be liable for any damage or injury resulting from my practice I understand and acknowledge that in undertaking Breathwork practices I am doing so at my own risk. It is with the understanding that I voluntarily execute this release and waiver.

Emergency Contact Name

Emergency Contact Phone Number

I certify that I am not currently pregnant, diagnosed with epilepsy, schizophrenia, bipolar, heart conditions, extremes of blood pressure, have a high risk of or past aneurysms, and I have not had a recent abdominal surgery.