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Breathwork Waiver
Breathwork Waiver
Name
(Required)
First
Last
Email
(Required)
Mobile Phone
(Required)
Emergency Contact - Name and Number
(Required)
Date of Birth
(Required)
Have you participated in any form of conscious breathwork before? If yes, where and with whom?
(Required)
What brings you to engage in this process at this time?
(Required)
Do you have any concerns or questions about participating in this event?
Please select if you have been hospitalised for a Diagnosed Psychiatric condition
(Required)
Yes
No
I hereby confirm that I read and understood the above information and have answered all questions completely and honestly, and have not withheld any information. My general health, other than as noted is good. I will not use alcohol or recreational drugs during this experience. I agree to not hold mindmattrz.org, as well as the teachers of the breath work experiences, and assistants against all loss, damage, liability or expense arising out of, or in connection with anything owned or controlled by mindmattrz.org, or resulting from any acts, failure to act, or negligence of mindmattrz.org. mindmattrz.org is not liable for any slips, falls or injuries while on the premises of the breath work experience. mindmattrz.org are not liable for any physical, medical or emotional experiences that may occur, however please notify someone immediately should something happen during the experience. I agree that use of the premises, facilities and equipment of mindmattrz.org is accepted by me at my own risk, and that mindmattrz.org is absolved and discharged from all liability for any loss or damage I may incur of my personal property.
Signature
(Required)
Date
(Required)
DD slash MM slash YYYY
