• Breathwork Health Declaration and Waiver

    Elements of Freedom with Jade

  • Please complete this form to declare your health status and provide consent for participation in breathwork sessions with Elements of Freedom with Jade.

    Participants must be aged 18 years or over to attend these sessions.

    Breathwork practices can have a significant effect on the body and mind and may not be suitable for everyone. Participants with certain medical conditions should seek advice from a doctor or qualified healthcare professional before taking part.

    As a precaution, participation is not recommended during pregnancy or for individuals with epilepsy, a history of seizures, or certain cardiovascular conditions unless cleared by a medical professional.

    All participants are responsible for informing the instructor of any relevant health conditions and for participating only to a level that feels safe and appropriate for them.

  • Date of Birth*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Format: 00000 000000.
  • Format: 00000 000000.
  • Date of Breathwork Session Attending
     - -
    2 digit day, 2 digit month, 4 digit year

  • Health Declaration

    Breathwork may not be suitable for everyone.

  • Additional care should be taken if you:

    • are pregnant

    • have epilepsy or a history of seizures

    • have a heart or cardiovascular condition (including uncontrolled high blood pressure)

    • have a severe respiratory condition

    • have recently had surgery or a significant injury

    • have glaucoma or a detached retina

    • have a significant mental health condition or history of psychosis, bipolar disorder, or another condition that may affect your participation

    • have any other medical condition that may affect your participation.

  • Do any of the above apply to you, or is there any medical condition, injury, treatment, medication, or other health information that your instructor should be aware of before you participate?*
  • Do you have any allergies?*
  • Are you deaf or hard of hearing?*

  • Marketing Communication

  • I am happy to receive occasional updates about workshops, events, and offers from Elements of Freedom with Jade via :

  • Photography & Social Media Consent

    Photographs and videos may be taken during sessions to promote Elements of Freedom with Jade and future events. Where a session is delivered as part of a retreat, event, or programme organised by a third party, photographs and videos may also be shared with the organiser for use on their website, social media, and promotional materials.

  • Privacy Notice

    The information provided on this form, including health information and emergency contact details, will be used solely for assessing suitability for participation, ensuring participant safety, and responding to any medical concerns or emergencies. Information will be treated confidentially and will only be shared with relevant event organisers, healthcare professionals, or emergency services where reasonably necessary for these purposes or where required by law.

  • Participant Declaration and Liability Waiver

  • By signing below, I confirm that:

    • I have completed this form honestly and to the best of my knowledge.
    • I have read and understood the health questionnaire, including circumstances in which participation may not be advisable and when medical advice should be sought before taking part.
    • I understand that it is my responsibility to disclose any relevant medical conditions, seek medical advice where appropriate, and inform the instructor of any changes to my health before the session. 
    • I understand that the services provided by Elements of Freedom with Jade are intended to support wellbeing and personal development and are not a substitute for medical advice, diagnosis, or treatment.
    • I understand the nature of the activities involved and voluntarily choose to participate, accepting responsibility for my own wellbeing and actions during the session.
    • If you are unsure whether breathwork is appropriate for you, please seek advice from your GP or another suitably qualified healthcare professional before participating.
    • I understand that breathwork practices may result in physical, emotional, or psychological responses, and I agree to stop and inform the instructor if I experience any distress or concerns during the session.
    • I acknowledge that I should listen to my body at all times and only participate to a level that feels safe and comfortable for me.
    • Where this session is delivered as part of a retreat, event, or programme organised by a third party, I consent to relevant health information being shared with the event organiser where reasonably necessary for participant safety, suitability to participate, or in the event of a medical concern or emergency.
    • I understand that if I become ill or injured during the session and am unable to make decisions for myself, the facilitator may seek appropriate medical assistance or contact my emergency contact where reasonably necessary.
    • I voluntarily assume all risks associated with my participation and release Elements of Freedom with Jade, Jade Axtell, and any assistants, contractors, or representatives from liability for injury, loss, or damage arising from my participation, except where liability cannot legally be excluded.
    • I have read, understood, and agree to the above.
    • I confirm that I am 18 years of age or older.
  • Date signed
     - -
    2 digit day, 2 digit month, 4 digit year
  • Should be Empty: