Girls Circle Application and Permission Form

Happy Health Institute 1152 Solano Ave., #2B, Albany, CA 94706

www.OnnaLoMD.com/girlscircle Support@OnnaLoMD.com 510-747-9033

Participant Name

First NameLast Name

Participant Preferred Name or Nickname (if applicable)

Participant Age

Participant Date of Birth

Participant Gender

Participant Address

Participant Preferred Pronouns

List of known allergies

Please tell us briefly about your child's strengths

Please tell us briefly about your child's interests

What are your hopes for your child in terms of participating in Girls' Circle?

Parent/Legal Guardian Name

Relationship to Child

Phone Number: (Primary)

Format: (000) 000-0000.

Phone Number:(Secondary)

Format: (000) 000-0000.

Email Address

example@example.com

Address: (If different from Child)

Parent/Legal Guardian Name

Relationship to Child

Phone Number: (Primary)

Format: (000) 000-0000.

Phone Number:(Secondary)

Format: (000) 000-0000.

Email Address

example@example.com

Address: (If different from Child)

Name of Pediatrician

Pediatrician's Clinic

Phone Number

Format: (000) 000-0000.

Emergency Contacts (put N/A if not applicable):

1. Name

1. Relationship

Phone:

Format: (000) 000-0000.

Alternative Phone

Format: (000) 000-0000.

2. Name:

2. Relationship

Phone:

Format: (000) 000-0000.

Alternative Phone

Format: (000) 000-0000.

Authorized Pick-Up List (put N/A if not applicable):

Please provide the names of individuals who are authorized to pick up your child outside of guardians. They may be asked to provide identification.

1. Name:

1. Relationship

Phone Number

Format: (000) 000-0000.

2. Name:

2. Relationship

Phone Number

Format: (000) 000-0000.

Name of my child:

My child has my permission to participate in the Girls Circle at Happy Health Institute. I understand that Girls Circle is an empowerment group that encourages creative and verbal expression and that the circle guidelines provide the foundation for circle communication.

1. Everything heard and said in Girls Circle stays in Girls Circle. It's confidential.Only matters which indicate possible harm to or by a circle participant will berevealed.

2. We can "pass" whenever we choose. No one will be pressured to speak.

3. We will talk about our own experiences. If we talk about others, it is only toexplain how they affect us in some way.

4. We will try not to advise others, but listen to them. If they ask for advice, we willshare any experience that we have that might be useful.

5. We will avoid interrupting others.

6. We will accept others' opinions and feelings as their own, without making themout to be wrong when they think differently.

7. We will participate in each meeting. If we have to miss a meeting, we will phonethe facilitator before the meeting so that people know what's happening with us.

I understand that I may contact the facilitator(s) with questions or comments about Girls Circle.

Facilitator Name: Cosette Taillac Facilitator Phone Number: 510-847-0730

Location: 1152 Solano Ave #2B, Albany, CA 94706

At Happy Health Institute, we know that your wellbeing is dynamic which is why we offereducational group classes and activities that supplements traditional family medicine andintegrative care. This agreement describes your obligations as a participant and specificconsents granted on behalf of yourself and/or other participants enrolled by you.

1) Scope. Your participation in Girls Circle may include a variety of topics from art, role-playingto mindfulness. Girls Circle Activities do not constitute professional medical services and nopatient-provider relationship is established by your participation. There is a fee associated withGirls Circle, you will be made aware of the fee in advance, and payment is due at the timeof registration. Girls Circle Activities are not billable to a third-party payor, no representationsregarding reimbursement are made, and such reimbursement is not anticipated.

2) Participation. Naturally, there are some reasonable risks of participation that youshould consider before registering for Girls Circle. Girls Circle will be led by anfacilitator who will make you aware of the rules of participation. You agree to abide bythose rules and refrain from any conduct that might intentionally or inadvertently createa risk of harm to yourself, another person, or property. You agree not to participate inGirls Circle if you are sick to avoid contagion for other participants. If you require specialaccommodations to participate, please let us know in advance of your registration. Inthe event you (over)hear or otherwise receive someone else’s private information, youagree to hold that information in strict confidence

3) Safety. Girls Circle Activities are exclusively recreational and voluntary. Happy HealthInstitute representations or warranties as to the safety or appropriateness of any Girls CircleActivities for any individual participant. Participation is at your own risk. By signing thisagreement, you voluntarily agree to assume all risks and accept sole responsibility for any injuryto yourself and/or other participants enrolled by you (including without limitation propertydamage, personal injury, illness, disability, and death) that may be incurred inconnection with Girls Circle Activities. On behalf of yourself and/or other participants enrolled byyou, you hereby release, covenant not to sue, discharge, and hold harmless Happy HealthInstitute, its owners, employees, agents, contractors, and representatives, of and from allliabilities, claims, actions, damages, costs, or expenses of any kind arising out of orrelating to Girls Circle Activities and/or your participation in them. You understand and agreethat this release includes any claims based on the actions, omissions, or negligence of Happy Health Institute, its owners, employees, agents, contractors, and representatives,whether such occurs before, during, or after participation in any Girls Circle Activities. In theevent of a claim arising from your negligence or malice in participation in Girls Circle Activities,you agree to indemnify and hold Happy Health Institute harmless from and against such liability.

4) Zero Tolerance Policy. Happy Health Institute has a ZERO TOLERANCE policy for firearmsand other weapons. Happy Health Institute prohibits the presence or use of alcohol, cannabis,nicotine/tobacco/vaping, and drugs (other than prescribed medication) at its facility andin relation to Girls Circle Activities . This policy includes everything identified above, as well asany other item that might reasonably cause harm to anyone at or near Happy Health Institute orGirls Circle Activities.

5) Miscellaneous. This agreement will be effective on the date it is signed and will remainin effect until it is canceled. Subsequent attachments, addendums, and the like areincorporated by reference as though fully set forth herein. You can terminate thisagreement at any time by providing us with written notice. The parties shall endeavorto amicably resolve any disputes arising under this agreement and if such endeavors areunsuccessful, you agree that final disposition of the dispute shall be resolved by bindingarbitration and enforced by any court of competent jurisdiction. The provider ofarbitration services shall be determined by Happy Health Institute. Notwithstanding anythingto the contrary, small claims actions brought by Happy Health Institute shall be exempt fromthe requirements of this provision. This document and attachments hereto constitutethe entire agreement between the parties with respect to the subject matter hereof andsupersede any and all other verbal or written agreements, representations, negotiations,and understanding. In the event that any provision of this agreement is held to beillegal or unenforceable for any reason, the unenforceability of that provision shall notaffect the remainder of this agreement, which shall remain in full force and effect inaccordance with its terms, and any offending provision shall be rectified to the minimumextent necessary for conformity with law unless it cannot be rectified in which case thisagreement shall be interpreted as though the offending provision had not existed. Nowaiver of a breach of any provision of this agreement will be construed to be a waiver ofthis agreement, or any other provision herein contained, whether of a similar ordifferent nature, and no delay in acting with regard to a breach shall be construed as awaiver of that breach.

I have read and agree to this Group Participation Agreement and my signature confirms that I intend to be bound to this agreement pursuant to its terms along with any appendices,attachments, exhibits, or schedules hereto.

I agree to abide by the rules of participation as expressed by Happy Health Institute, staff, and instructors, and anyone affiliated with running Girls Circle. If you are registering participants other than yourself, including children, your signature means that you have the authority to act on their behalf and you are responsible for such participants.

Parent/Guardian Signature

Name of Signatory

Date

Name of Enrolled Participant

The following are Specific Consents that grant additional permissions to Happy Health Institute, its staff, and instructors. Please indicate your agreement to Specific Consents by checking the box associated with the permission you are granting. Please check the box to grant consent.

Please Check each box to grant specific consent.

I and/or the other participants enrolled under this agreement have the following known health conditions, allergies, and dietary restrictions:

Health conditions, Allergies, Dietary restrictions:

Parent/Guardian Signature

Name of Signatory

Date

Name of Enrolled Participant

Don't forget to go to the payment link after you submit the form to complete the application. (It's in your email)

Girls Circle Application and Permission Form

Participant Information

Parent / Guardian Information

Pediatrician Information:

Permission

GIRLS CIRCLE GUIDELINES

Group Participation Agreement

SPECIFIC CONSENTS