For the purposes of this Release and Waiver, the term “Releasees” shall refer to any or all of:
1. Name of Practitioner: Daniel Zalcberg
2. Name of organization, company, or legal entity: Ki Wellness Pty. Ltd T.A Life Medicine Collective
3. The heirs, assigns, successors, employees, volunteers and/or associates of Daniel Zalcberg and/or Ki Wellness Pty. Ltd
I understand and acknowledge that the discussions, consultations, and Life Medicine Collective session(s) I have, the Releasees:
a) are not intended to replace any relationship I have with my medical doctor and/or primary health care provider(s);
b) are not intended to constitute medical advice or any substitution for medical care;
c) are not intended to be relied on for prescriptions, recommendations, diagnosis or treatment in relation to any health problem or disease;
I understand that if I am taking any medications or have any medical conditions such as, but not being limited to: schizophrenia, bi-polar, epilepsy, heart conditions, or pregnancy, that I must advise the facilitator/s.
I also understand that even though I have been accepted as a participant, I am responsible for any consequence resulting from Life Medicine Collective Session.
I certify that I have consulted a health professional regarding any condition physical, mental or emotional that could interfere with my judgment, or affect my health in any way during or after The Life Medicine Collective session.
I understand and acknowledge that I am responsible for consulting my health care provider or doctor in case I have or suspect to be suffering from a health problem.
I understand the stories or testimonials presented before or during the session do not constitute a warranty, guarantee, or prediction regarding my experience during or after the session. The Life Medicine Collective facilitators make no warranty, guarantee, or prediction that I will experience any particular state of awareness or consciousness during or after “The Session”, nor does it make any representation that I will experience any particular outcome on an issue.
I further understand that my participation in “The Session” is not intended to create nor does it establish a client-practitioner relationship or any other type of therapeutic or professional relationship between me Daniel Zalcberg and The Life Medicine Collective facilitators.
I understand that The Life Medicine Collective Session could include a physical touch designed to support me in my path.
I understand and acknowledge that by participating in The Life Medicine Collective Session, I do it at my own risk. It is with this understanding that I voluntarily sign this waiver. Since the Session is experiential and the extent of the Session’s risks and benefits are not fully known, I agree to assume and accept full complete responsibility for any known and unknown risks associated with my participation in the Session, including any physical injury, psychological or emotional effects, death, loss, or property damage.
I agree and understand the Session may be filmed, photographed and/or recorded and that Daniel Zalcberg and the Life Medicine Collective shall have all rights in and to such film, photographs and/or recording, including the copyright therein. The copyright shall include, but not be limited to, the right to use, re-use, publish, and re-publish and otherwise reproduce, modify, and display any such film, photograph and/or recording for educational and promotional purposes, including without limitation, audiotapes, audio CDs, DVDs, websites, video, or film or any other form of recorded images.
I grant Daniel Zalcberg and The Life Medicine Collective the right, without compensation to myself, to film, photograph and/or record you while participating in the Session and I waive any right which I now have or may have hereafter in any such film, photograph and/or recording. I agree to not record by audio, video, photographic or any other means, any portion of the Session.
In my personal name, that of my heirs and assignees, I exonerate and totally and indefinitely release the relinquishes of any suit, complaint, declaration, damage, cost and / or expense of any kind (that any such prosecution, complaint, declaration, damage, cost and / or expense is caused by the passive or active negligence of the Releasees or otherwise) in connection resulting from any discussion, consultation and / or Session I had.
Please acknowledge that you understand this Disclaimer, Waiver, and Acceptance of Personal Responsibility by affixing your signature below.