Client Intake Form

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Format: (000) 000-0000.

E-mail

example@example.com

Date of Birth

Date

How did you hear about us?*

Please Specify*

Have you ever done Breathwork before? If yes, please indicate what types:

What is your current occupation?

What is your current relationship status?

How would you rate your current stress?

1 is Low, 5 is High

Roughly many alcoholic beverages do you consume per week?

Do you use any recreational drugs? If yes, please indicate which ones and frequency per week:

Do you have any health conditions? If yes, please describe below and indicate any medications you are currently on:

What brings you to Release Breathwork and what goals would you like to achieve?

RELEASE BREATHWORK WAIVER

LIABILITY WAIVER, AWARENESS OF RISKS, GENERAL ASSUMPTION OF RISK & LIMITATION OF LIABILITY

By signing this contract and/or checking the box below, I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself including, but not limited to, personal injury, disability, death, illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with RELEASE BREATHWORK and/or its affiliates or participation in RELEASE BREATHWORK programming or trainings whether online, in studio or at any event. On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless RELEASE BREATHWORK and/or its affiliates, its employees, agents, and representatives, of and from the programming, or trainings including all liabilities, claims, actions, damages, or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of RELEASE BREATHWORK and/or its affiliates, its employees, and representatives.
In signing this contract I agree to:

I acknowledge that the instruction offered by RELEASE BREATHWORK and/or its affiliates is limited to that of instruction in Breathwork, Meditation, and Somatic modalities.
I acknowledge that there are risks associated with participation in any or all the programs offered by RELEASE BREATHWORK. I have informed myself and understand the risks associated with my participation in these activities and I freely accept these risks.
I understand that I am free to withdraw from or reduce my participation at any time.
I am not aware of any medical condition that would affect my ability to participate in the programs offered by RELEASE BREATHWORK. If I have any concerns about my medical condition, I will consult with my physician before participating.
I acknowledge that the following contraindications pose no health concerns/risks to me;

AWARENESS OF RISKS
I acknowledge that the following contraindications pose no health concerns/risks to me;

A history of cardiovascular disease, including angina or heart attack, high blood pressure, use of pace-maker
Glaucoma or Retinal detachment
Osteoporosis
Significant recent physical injuries or surgery
Mental illness or seizure disorders that require a doctors supervision
Persons who have experienced a psychotic episode requiring hospitalization
Women who are pregnant should ALWAYS consult with their primary care physician before breathwork
It has been highly suggested that this work is not suitable for anyone with a personal or family history of aneurysms.
Persons with asthma should bring their inhaler and consult with their primary care physician and the Breathwork session facilitator.

 RELEASE AND WAIVER
 In consideration of the acceptance of my registration for the activities and programs offered or sponsored by RELEASE BREATHWORK, I hereby for myself, my heirs, executors, administrators, or any others who may claim on my behalf, promise not to sue, and hereby waive, release and discharge RELEASE BREATHWORK and anyone acting for or on its behalf, from any and all claims of liability for personal injury, illness, loss of life or property damage of any kind or nature, arising out of or sustained in the course of my participation in the activities and programs offered or sponsored by RELEASE BREATHWORK or related events. This Release and Waiver applies to all claims, foreseen or unforeseen, including negligence and breach of statutory or other duty of care (including that owed under The Occupier's liability Act). I acknowledge and agree that during the course of participating in activities, programs and events offered or sponsored by RELEASE BREATHWORK throughout the world, I may be photographed, taped, recorded or broadcast and I agree to the unrestricted use (alone or together with other materials) of my image or likeness for use on print, web, publications, advertisements, social media, non-theatrical, home video, Internet, any other electronic medium presently in existence or invented in the future, etc. I also understand that no compensation, fee or royalty will be payable to me from such usage.

I agree that this Agreement and Release and Waiver is intended to be as broad and inclusive as permitted by law. Any provision found to be invalid or unenforceable by a court shall not affect the validity or enforceability of any other provision. I hereby agree that I will not bring or consent to others bringing claim or action against RELEASE BREATHWORK on the grounds that anything contained in the Property, or in the advertising and publicity used in connection herewith, is defamatory, violates any other right whatsoever, including, without limitation, rights of privacy and publicity. I hereby release RELEASE BREATHWORK, its organizers, directors, agents, officers, officials, servants, representatives, assigns and successors from and against any and all claims, demands, actions, causes of actions, suits, costs, expenses, liabilities, and damages whatsoever that I may hereafter have RELEASE BREATHWORK and/or its affiliates to use the Property or to use any of the rights granted hereunder, or to prepare, produce, exhibit, distribute or exploit the Property.

By engaging in a relationship with RELEASE BREATHWORK, I agree to be bound by this policy and it forms part of my agreement with the organization and/or its affiliates. I understand that RELEASE BREATHWORK strongly recommends that I consult with my physician prior to commencing any classes and programs. By signing this document, I acknowledge that I have been fully informed of the possibility of adverse physiological and physical occurrences. By signing this document, I assume all risk for my health and well-being, and fully release and hold RELEASE BREATHWORK, its instructors, members and employees. I release RELEASE BREATHWORK of the foregoing and each of their respective partners, officers, directors, employees, volunteers, agents, executors, administrators, successors, and assigns ("the Released Parties") at my own risk and I agree to forfeit any and all forms of legal recourse which may be available to me, including but not limited to any form of damages, as a result of your participation in the classes or programs.

I have read this document carefully and acknowledge that I have complete knowledge and understanding of its contents. I recognize that by signing this document I am waiving certain legal rights, including the right to sue. I am signing this document voluntarily. I am over the age of 18 years old.

Signature