Participant Contract Release, Waiver, and Indemnity of Liability Agreement Please fill in your name at the top of this form and then again at the bottom of this form along with your e-mail and telephone number and then submit. Participant Name (First Last):*This Participant Contract and Release, Waiver and Indemnity of Liability Agreement (hereinafter “Agreement”) is entered into by Participant and Holotropic Breathwork LA LLC (“Organizer”). In consideration of being permitted to participate in the activities involving Inner Awareness Breathwork ("IAB"). The Parties hereby agree as follows:* 1. This Agreement is made and entered into under the laws of the State of California and the United States and shall be interpreted, governed and enforced under and pursuant to these laws. The term of this Agreement is for periodic sessions over the next twelve months. 2. Participant agrees that should an action be brought against Organizer and/or any Holotropic Breathwork Facilitators or Apprentices working at the Program for any reason whether to enforce the terms of this agreement or on some other basis, that all disputes between Participant and Organizer will be litigated in Los Angeles County, California and Participant waives any rights he/she may have in litigating in any other jurisdiction. 3. Participant certifies that he/she is not pregnant and does not have epilepsy, a detached retina, glaucoma, uncontrolled high blood pressure, cardiovascular disease and/or irregularities including but not limited to prior heart attack; prior diagnosis by a Medical Professional of bipolar disorder or schizophrenia; strokes, TIAs, seizures or other brain/neurological condition or disease; immediate family history of aneurysms, use of prescription blood thinners such as Coumadin, hospitalization for any psychiatric condition or emotional crisis within the last ten years, osteoporosis that is serious enough whereby intense movement could cause physical issues, recent physical injuries that are not fully healed and could be re-injured through intense movement, or any other medical or physical conditions which would impair or affect his/her ability to engage in any activities that involve physical and/or emotional release or which would cause any risk of harm to Participant, other participants and/or any participating Holotropic Breathwork Facilitators or Apprentices or otherwise endanger Participant’s health while participating in an Neurodynamic Breathwork session organized by Holotropic Breathwork LA LLC. If you have any doubt about whether you should participate, consult your physician or therapist as well as a Facilitator before attending. Participant also certifies that if he/she has asthma that he/she has brought his/her inhaler. 4. Participant is aware that certain activities he/she may engage in during the Program are physically, emotionally and/or mentally stressful. 5. Participant understands that this Neurodynamic Breathwork Event is intended as a personal growth experience and should not be used as a substitute for psychotherapy. 6. Participant agrees to comply with the stated and customary guidance and norms of participation in NDB. If, however, Participant observes any unusual hazard during his/herparticipation, participant will immediately remove himself/herself from participation in IAB and bring such to the attention of the Organizer or a Facilitator forthwith. 7. Participant knows, understands and acknowledges that Organizer and/or Holotropic Breathwork Facilitators and/or Apprentices are NOT physicians, psychologists, or healthcare professionals, and that NDB is NOT intended to treat or diagnose, and does NOT include treatment for or diagnosis of, any illnesses, disease or disorders, whether physical, mental, psychological or emotional. 8. Participant acknowledges, understands, and agrees that this Agreement, and all of the releases, terms and conditions contained herein, shall apply with equal force and govern any future IAB Programs, both in-person and online, in which participant partakes with Organizer thus obviating the need for me to sign this Agreement each and every time I partake in any NDB activities or events. Participant further agrees to bring any changes in their Medical condition to Organizer’s attention before participating in any IAB event. 9. Participant understands and agrees that, if this is an in-person NDB Program, Organizer is not responsible for property that is lost, stolen, or damaged while in, on, or about the premises. 10. Participant understands that since his/her experience will be guided by his/her own psyche/inner healer, despite any representations made by any of Organizer or Organizer’s staff, or any marketing materials that Participant may have seen regarding NDB, Organizer cannot guarantee any specific type of experience, result or benefit from participating in the IAB Program. 11. Participant agrees to assume full responsibility for his/her own physical, emotional and mental health and hold harmless Organizer, and/or any Holotropic Breathwork Facilitators and Apprentices working with organizer at the Program from any physical, emotional and/or mental damage that may be attributed to it. Participant further holds harmless organizer from any and all loss, liability, injury, damage or cost which may arise out of or in connection with participation in the Program. 12. Participant acknowledges that he/she has been advised (a) concerning the types of activities which will be engaged in during the Program, and understands the risks and difficulties that may arise during the Program; and (b) that if Participant feels too uncomfortable to continue at any point during the breathwork, he/she is to stop immediately and check in with Organizer before continuing. . Participant understands that he/she may decline to do any of the activities. Participant understands that by executing this release and engaging in the Program, he/she is assuming those risks which are inherent to the activities involved. Participant further understands that these activities are best done in presence of or conjunction with the Organizer, for best results. 13. Participant understands that contra-indications may exist for the anticipated activities if Participant is or has been suffering medical or psychological / psychiatric conditions requiring professional care; and that the activities described can also trigger suppressed traumas. 14. Participant agrees to keep confidential any comments, shares or experiences by other participants. 15. Participant understands and agrees that he/she is attending and participating in the Program at the discretion of Organizer, which attendance and/or participation can be terminated at any time without being informed of the reason therefor. Participant may not record – audio or video – any of these sessions or any persons participating therein. Still photographs will not be taken of any person except with the advance consent of the person being photographed. 16. Participant waives, releases and discharges any and all claims, rights and/or causes of action which he/she now have or which may arise out of or in connection with participation in the Program as well as which may arise out of or in connection with Participant’s participation in the activities associated with the Program. Therefore, under no circumstance will Participant prosecute or present any claim for personal injury, property damage or any other cause of action against Organizer and/or and participating Holotropic Breathwork Facilitators and Apprentices. 17. This agreement is binding on Participant’s heirs, assignees, dependents, personal representatives and estate. 18. No oral representations, statements or inducements have been made to Participant to cause them to enter into this agreement. 19. At the choosing of Organizer and/or any participating Holotropic Breathwork Facilitator or Apprentice any claim or controversy that arises out of or relates to this agreement, or the breach of it, may be settled by arbitration in accordance with the rules of the American Arbitration Association. Such arbitration shall occur in the County of Los Angeles, State of California and be binding upon the parties and Judgment upon the award rendered may be entered in any court with jurisdiction. 20. Should Organizer and/or any participating Holotropic Breathwork Facilitator or Apprentice be successful in bringing an action to enforce the terms hereof or successful in defending itself from a suit brought by Participant, Organizer and/or any participating Facilitator and/or Apprentice shall recover all costs and expenses incurred in such action, including reasonable attorneys’ fees. 21. Should any provision of this Agreement be held invalid or illegal, such illegality shall not invalidate the remainder of this Agreement. In that event, this Agreement shall be construed as if it did not contain the invalid or illegal part, and the rights and obligations of the parties shall be construed and enforced accordingly. * I have read this agreement and understand it contains release of all claims language for injuries and damages and I have either consulted an attorney or, at my sole discretion, elected not to do so. I voluntarily sign my name evidencing acceptance of the provisions of this agreement. If English is not my native language I have either studied enough English to be able to read and understand this agreement, or I have had this agreement explained to me in my native language. Participant Name::*Date:*Participant E-mail:*Participant Best Contact Phone: This iframe contains the logic required to handle Ajax powered Gravity Forms.
