Group CCB Intake Form

Group CCB Intake Form
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is it ok to send messages to either email or phone about this event?
Emergency Contact Name, Number, and Relationship to you
How did you hear about this event?
Conscious cannabis breathwork circles are a gentle yet powerful way to benefit from a therapeutic psychedelic experience.However, under some circumstances, participation is not recommended, and can be contraindicated for your own health and well-being. Please note that anyone experiencing the following conditions should not participate:Pregnancy or breastfeedingHistory of psychosis or other related disordersDissociative Identity Disorder (DID), any Personality Disorders, Bipolar Disorder, Schizophrenia or other Severe Mood DisordersCardiovascular problems, severe hypertension, recent surgery or fractures, acute infectious illness, severe asthma, or epilepsy.If you have any questions about your ability to safely participate given these or any other conditions, please contact us to discuss further. Otherwise, by initialing below, you are agreeing that you do not have any of the conditions above.
Also, by initialing below, you agree to get a ride home for your own safety, as you will still be feeling the effects of the cannabis after the event closes.
RELEASE OF LIABILITY ; In exchange for participation in the activity of retreats held at Moss Village, Octobarn, and/or Moss Hollow at the property of Jo Wunderly. ______________________________________________________________________________________________ 1. Agreement To Follow Directions. I agree to observe and obey all posted rules and warnings, and further agree to follow any oral instructions or directions given by Jo Wunderly, Lara Hutch, Rachel Berry, or the employees, representatives, or agents of Jo Wunderly. 2. Assumption of the Risks and Release. I recognize that there are certain inherent risks associated with the above-described activity and I assume full responsibility for personal injury to myself and (if applicable) my family members, and further release and discharge Jo Wunderly, Lara Hutch and Rachel Berry for injury, loss, or damage arising out of my or my family's use of or presence upon the facilities of Jo Wunderly, whether caused by the fault of myself, my family, Jo Wonderly, Lara Hutch, Rachel Berry or other third parties. 3. Indemnification. I agree to indemnify and defend Jo Wunderly, Lara Hutch and Rachel Berry against all claims, causes of action, damages, judgments, costs, or expenses, including attorney fees and other litigation costs, which may in any way arise from my or my family's use of or presence upon the facilities of Jo Wunderly. 4. Fees. I agree to pay for all damages to the facilities of Jo Wunderly caused by any negligent, reckless, or willful actions by me or my family. 5. No Duress. I agree and acknowledge that I am under no pressure or duress to sign this agreement and that I have been given a reasonable opportunity to review it before signing. I further agree and acknowledge that I am free to have my own legal counsel review this agreement if I so desire. 6. Dispute Resolution. The parties will attempt to resolve any dispute arising out of or relating to this agreement through friendly negotiations among the parties. If the matter is not resolved by negotiation, the parties will resolve the dispute using the below Alternative Dispute Resolution (ADR) procedure: Any disputes arising out of or relating to this agreement will be submitted to mediation in accordance with any statutory rules of mediation. If mediation does not successfully resolve the dispute, then the parties may proceed to seek an alternative form of resolution in accordance with any other rights and remedies afforded to them by law. I HAVE READ THIS DOCUMENT AND UNDERSTAND IT. I FURTHER UNDERSTAND THAT BY SIGNING THIS RELEASE BY TYPING MY NAME BELOW, I VOLUNTARILY SURRENDER CERTAIN LEGAL RIGHTS.
We look forward to seeing you!
Payment details
Payment can be made via Venmo, @Lar26 or @Rachel-Berry-0
Contact us if you would like to pay cash.
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