Name of Participant *

First Name

Last Name

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

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Liability Release *

As the client, and in consideration for my participation in breathwork sessions (the "Session") with Angela Reiner (the “Facilitator”), I agree that my participation in the Session is entirely voluntary and that I assume any risk associated with participation. Any actions or lack of actions, taken by me, the client, of such advice is done so solely by choice and responsibility, and any harm, injury, or loss that may occur to me or my property as a result of my participation in the Session, is neither the responsibility nor liability of The Flourishing Co LLC or its trained Facilitator. I understand that breathwork is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and I will not use it in place of any form of therapy. I recognize that breathwork requires emotional, physical, and mental effort, exertion, and behavioral experimentation, on my part, which may cause physical, mental or emotional injury. I understand that The Flourishing Co LLC will not diagnose conditions, nor do they prescribe medicines, nor interfere with the treatment of a licensed medical professional. It is recommended that I seek a licensed health care professional for any physical or psychological ailment I have. I fully acknowledge and take full responsibility for all the risks involved. I understand that it is my responsibility to consult with my health care provider prior to participating in the Session. In the event that I am injured, I agree to assume any financial obligation, either through my personal health insurance, or through some other means, for any medical costs I incur. The Flourishing Co LLC and Facilitator assume no responsibility for any medical expenses, injury, or damage suffered by me in connection with the use of any facilities or services in connection with the Session. IN CONSIDERATION OF MY PARTICIPATION IN THE SESSION, I HEREBY GENERALLY RELEASE, AND PROMISE TO INDEMNIFY, DEFEND, AND HOLD THE FLOURISHING CO LLC AND Facilitator, AND THEIR RESPECTIVE AGENTS AND EMPLOYEES (THE “RELEASE PARTIES”), FROM ANY LIABILITY WHATSOEVER. I will reimburse The Flourishing Co LLC and Facilitator for any damages, reasonable settlements and defense costs, including attorney’s fees, that they incur because of any such claims made against them. I agree that the terms of this agreement, including the indemnification obligations in this paragraph, will be binding on my estate, and my personal representative, executor, administrator or guardian will be obligated to respect and enforce them. This RELEASE does not extend to claims for gross negligence, intentional or reckless misconduct, or any other liabilities that applicable law does not permit to be excluded by agreement. I agree that the purpose of this agreement is that it shall be an enforceable RELEASE OF LIABILITY AND INDEMNITY as broad and inclusive as is permitted by law. I agree that if any portion or provision of this agreement is found to be invalid or unenforceable, then the remainder will continue in full force and effect. I also agree that any invalid provision will be modified or partially enforced to the maximum extent permitted by law to carry out the purpose of the agreement.

Yes, I agree to the above conditions

No, I do not agree to the above conditions

Have you ever done breathwork before? *

Yes

No

Do you have any other health-related disease, condition, or concern that breathwork facilitators should be aware of? *

Yes

No

Date *

MM

DD

YYYY