Clone of Register-WELLTH Experience

WELLTH Lab Participant Registration, Intake & Consent Form

WELLTH Lab is a program of Experience WELLTH, the dba of Knowledge + Skills = Options Consulting, LLC. connect@experiencewellth.com
SECTION 1. PARTICIPANT INFORMATION
Full Name*

First NameLast Name
E-mail Address*
Yes, I want to receive Experience WELLTH updates via emailNo, I prefer not to receive Experience WELLTH updates via email
Mobile Number*

Area CodePhone Number
Yes, I want to receive Experience WELLTH updates via textNo, I prefer not to receive Experience WELLTH updates via text
18 - 2425 - 3435 - 4445 - 5455+
I have no food allergiesI have food allergies (list below)I have no dietary restrictionsI have dietary restrictions (list below)
List food allergiesex: nuts, dairy, shellfish, none* . List dietary restrictions ex: Vegetarian, Vegan, Pescatarian, none* .
SECTION 2: EMERGENCY CONTACT
Emergency Contact Name*

First NameLast Name
Relationship to You*
Emergency Contact Phone Number*

Area CodePhone Number
SECTION 3. WELLBEING CHECK-IN (OPTIONAL)

This question is optional and will be used only to help us hold space with care.
In one or two sentences, what are you hoping to receive or explore during this WELLTH Lab?
SECTION 4. PARTICIPANT ACKNOWLEDGEMENTS & CONSENT
I understand that WELLTH Labs are non-clinical wellbeing and healing experiences focused on rest, reflection, movement, community, and liberation-centered practices.I understand that WELLTH Labs do not provide medical care, mental health treatment, or psychotherapy, and are not a substitute for professional medical or mental health services.I acknowledge that I am responsible for listening to my body and choosing my level of participation throughout the Lab.I confirm that I am physically and emotionally able to participate in gentle movement, seated practices, or rest-based activities, and I will modify or stop participation if needed.I understand that participation is always voluntary, and I may step away, rest, or decline any activity at any time without explanation.I understand that some practices may involve optional, consent-based touch, and that facilitators will always ask for verbal consent before any touch.I understand that I may say no to touch at any time and that my boundaries will be respected without question.I understand that WELLTH Labs are intentionally designed as culturally safe spaces for Black women of the diaspora.I agree to uphold community confidentiality and not share personal stories or identities of other participants outside of the Lab without their explicit permission.I agree to engage with others with respect, care, and non-judgement.
SECTION 5. LIABILITY WAIVER
I acknowledge that I am participating in WELLTH Lab voluntarily and assume full responsibility for my participationI release and hold harmless Knowledge + Skills = Options Consulting, LLC dba Experience WELLTH, WELLTH Labs, its owner, facilitators, practitioners, volunteers, and venue from any and all liability, claims, demands, or causes of action arising from my participation, except in cases of gross negligence.I understand that any injuries or discomfort that may occur are my responsibility to manage and communicate.
SECTION 6. PHOTO & MEDIA RELEASE

Please select one option:
Yes, I consentNo, I do NOT consent
SECTION 7. PAYMENT & CANCELLATION POLICY
I understand that my registration is confirmed upon payment.I understand that cancellations or no shows are nonrefundable.I understand that in the event of severe weather or unforeseen cirmcumstances, Experience WELLTH may cancel or reschedule the Lab, and I will be notified of next steps
Please sign your full name below to indicate your understanding and agreement with the above.*

Clear
Date

MonthDayYear
Date

My Products*

WELLTH Lab - Charlotte$233.00

A one-day experience for Black women of the diaspora for rest, reflection, and healing. The experience includes multi-modal wellness and healing practices, a nourishing lunch, and community connections. March 14 10:00 am - 2:45 pm at QCFit Yoga.

Quantity
Item subtotal:$0.00

Enter coupon

Total $0.00

Payment Methods

Credit Card

ACH Bank Transfer

Thank you for completing your registration.

You have opened the door to more for yourself and for your community!
Should be Empty:

WELLTH Lab Participant Registration, Intake & Consent Form

SECTION 1. PARTICIPANT INFORMATION

SECTION 2: EMERGENCY CONTACT

SECTION 3. WELLBEING CHECK-IN (OPTIONAL)

SECTION 4. PARTICIPANT ACKNOWLEDGEMENTS & CONSENT

SECTION 5. LIABILITY WAIVER

SECTION 6. PHOTO & MEDIA RELEASE

SECTION 7. PAYMENT & CANCELLATION POLICY

Payment Methods

Thank you for completing your registration.