Waiver for Breathwork Masterclass Gathering 2022 "*" geeft vereiste velden aan Your detailsName* First Name Last Name Email address* Emergency ContactIn case of emergency during the gathering, we will reach out to the person below.Name & Relation* Phone Number*IntentionsThis is mainly for your own awareness, but also good for us to know.What is your intention for joining this retreat?*Have you ever done a Plant Medicine Ceremony before? If yes, please mention which medicines you've worked with and specify briefly* Waiver of ResponsibilityDuring the gathering we will be working with several healing modalities, namely plant medicines, cold(ice bath), heat(sauna) & of course breathwork. The modalities we will be doing come with risks. It could bring up feelings of fear, anger, frustration, confusion or other negative psychological effects, and in exceptional cases can lead to psychosis or schizophrenia. The use of these substances (and therefore joining this gathering) is in all cases entirely at your own risk. The gathering organizer, ceremony holder, affiliated partners and companies can in no way be held liable for the consequences of joining this gathering and taking part in its modalities. Contra Indications The gathering should not be joined in the following cases (participant has the right to request a refund, but be sure to reach out to us first): Pregnancy or breastfeeding history of schizophrenia or other psychological disorders addiction (such as alcohol), an addiction history currently under treatment by a doctor or psychologist use of medication Inability to look at oneself or take responsibility. Answer the following questionsIf you have to answer "no" to any of these questions, fill in "no" and reach out to us.I am aware of the risks involved in attending this ceremony and of the contraindications.* Yes No I declare that I am in good health and currently not on any (prescription) medication.* Yes No I declare that I am not currently being treated by a physician, psychiatrist, or psychologist, or have been treated for addiction, schizophrenia, or other psychological disorders.* Yes No I declare that I am not pregnant or breastfeeding at this time.* Yes No I declare that I am well able to look at myself, to take responsibility for my own choices, interpretations and (mental) process.* Yes No I declare that I will never hold the ceremony organizer, ceremony holder, affiliated partners and companies liable for both the anticipated and unforeseen risks or consequences of attending this ceremony.* Yes No I understand that this statement is binding as a contract, is not for informational purposes only, and I declare that I have signed this document of my own free will.* Yes No Δ
