9D Participation Waiver Name * First Name Last Name Email * Phone * (###) ### #### Date * MM DD YYYY How did you hear about us? * Agreement * I, the participant, understand that by checking this box, I acknowledge that I have read, understood, and voluntarily agree to the terms of this liability waiver. I understand that I have waived certain legal rights and assume full responsibility for my participation. --------------------------------------- Breathwork sessions facilitated by Josephine Ethier involve physical, emotional, and psychological risks. I acknowledge that I am choosing to participate voluntarily and that I am responsible for my own well-being. Medical Considerations & Contraindications I understand that breathwork may not be suitable for individuals with certain medical or psychological conditions. I confirm that I do not have any of the following conditions: - Cardiovascular issues - Epilepsy - Psychosis, paranoia, or other severe psychiatric symptoms - Recent surgeries - Currently pregnancy - Use of heavy medication that may impair awareness or bodily function Any other medical condition that may be adversely affected by breathwork If I have asthma, I agree to bring my inhaler and consult with both my physician and the facilitator before participating. I understand that this list is not exhaustive. If I have a condition not listed above, I take full responsibility for consulting with a physician before participating. Acknowledgment of Risk & Informed Consent I understand that breathwork can induce intense physical, emotional, and psychological responses, including but not limited to: - Changes in heart rate, blood pressure, or breathing patterns - Dizziness, tingling, or temporary loss of sensation in extremities - Emotional releases, including crying or feelings of euphoria - Altered states of consciousness I acknowledge these potential effects and accept full responsibility for my experience. Facilitator’s Role & Disclaimer I understand that Josephine Ethier is a certified breathwork facilitator but not a medical doctor, psychiatrist, therapist, or licensed healthcare provider. Breathwork sessions do not diagnose, treat, or replace medical, psychological, or therapeutic care. I am responsible for seeking appropriate medical advice before engaging in breathwork. Assumption of Responsibility & Release of Liability I voluntarily assume all risks associated with breathwork sessions facilitated by Josephine Ethier. To the fullest extent allowed by law, I agree to release, indemnify, and hold harmless Josephine Ethier, along with any assistants, staff, or representatives, from any claims, liabilities, injuries, damages, or expenses that may arise from my participation. I accept full financial responsibility for any medical care required as a result of my participation. Severability Clause If any provision in this waiver is found to be legally invalid, the remaining provisions shall remain in full effect. I agree I do not agree Thank you!
