5Rhythms® BODY LAB with Tata Leban

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Event Timing: Tuesday April 16th - 8:30pm-10:30pm
Event Address: SIX AUTHORIZED SCHOOL 28 Lado Asatiani St. Tbilisi, Georgia

Email: tata.leban@gmail.com

Firs and Last Name *

What would you prefer to be called?
*

Email *

Phone Number *

Have you danced 5Rhythms before? *

Class

Workshop

Never

Required

Any allergy about copal or incense?
*

Please be aware. We do not allow any fragrance or essential oils at the class as some people are allergic with it
*

I understand

Required

Medical Disclaimer

This group experience is not intended to be a substitute for individual counseling or intensive psychological therapy. We are not mental health practitioners and do not have the expertise to perform as such. We do not provide medical or psychological advice, diagnosis or treatment and the opinions and teachings provided in the workshop are not intended to be substituted as medical or psychological advice, and should not be considered counseling, therapy or any form of medical or psychological treatment.

This is a group program and our focus is to provide a therapeutic group setting and ensure the well-being of both individual participants and the well-being of the entire group.

As part of our registration process, we collect medical disclosure information from each participant. This, along with all of the registration information, will be held in confidence.

We kindly request that you disclose, with as much detail as possible, any relevant information concerning any known past or present physical, emotional, or mental health issue, injury or condition. We will review this information as part of the registration process. Please let us know if you have any questions about your ability to participate in the immersion..

Please note that if a participant requires intensive medical or psychological care during the workshop staff may deem it necessary to seek off-site medical or psychological professional assistance. It may also result in a participant having to leave the immersion if the safety and or well-being of the participant and/or the group is jeopardized. If this occurs, departure costs will be the responsibility of the participant and there will be no immersion refund issued.

Yes

I acknowledge and accept the Medical Disclaimer

Have you ever received or are you currently receiving psychiatric care? If yes, please provide details on the reasons for your care
*

Do you have any mental or medical conditions that may be aggravated due to physical work or psychological stress? If yes, please provide details.
*

Is there anything else you think we should know?
*

Please confirm that you have completely and honestly answered the health questions above.

I have completely and honestly answered the health questions above.

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Agreements + Liability:Untitled Title

I agree to refrain from consuming mind altering drugs or alcohol before the sessions.

I Agree

In the case of an emergency, I acknowledge that I am responsible for my own health care costs. *

I Agree

I will not hold Tata Tamar Lebanidze, or 5Rhythms® Global or any other teacher, assistants, or participants of this immersion legally responsible for any injury, illness, accident, or other misfortune that may occur in connection with my participation during the classes taking place in Tbilisi, Georgia.

I attest that all of the information I have provided is correct and true. I am responsible for my own personal safety and wellbeing during the online course. I will not hold the organizers or leaders of this series nor any of the other participants responsible for any act that is or may be detrimental to my person or health in whatever way. I acknowledge all the information I have given to be true and transparent.*

I Agree

Signature *

Today's Date *

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Per Class fee 40gel.

TBC BANK: GE61TB7439945068100008

GEO BANK: GE59BG0000000585816213

In the note: provide your full name and specify the purpose of the transfer.

Paid - please complete the payment first, before submitting this form

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