Release Of Liability
This form must be completed prior to your first session. You only need to complete this form once.
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Name *
Email *
Today's Date *
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MEDICAL EXCLUSIONS:  Please check with a physician prior to participating in breathwork if you have/are experiencing any of the following medical conditions: angina, cardiovascular disease, heart attack, high blood pressure, glaucoma, retinal detachment, osteoporosis, seizure disorder, recent injury or surgery, any condition for which you take regular medication, history of panic attacks, psychosis or disturbances, severe untreated mental illness, family history of aneurysms, frequent dizziness or vertigo, currently pregnant.  I have read the medical exclusions and am not currently experiencing any of the conditions listed. *
Have you ever done breathwork? If so, what was your experience like? *
Do you have any unprocessed emotional trauma? If yes, please give a brief explanation of any unprocessed emotional trauma that may arise in our breathwork session together. *
Emergency Contact: Name and Phone Number *
As the client, and in consideration for my participation in breathwork sessions with Meagan Cole, Rise Up Shine Bright, I agree that my participation in the session is entirely voluntary and that I assume any risk associated with participation. Any actions or lack of actions, taken by me, the client, of such advice is done so solely by choice and responsibility, and any harm, injury, or loss that may occur to me or my property as a result of my participation in the session, is neither the responsibility nor liability of Rise Up Shine Bright or Meagan Cole. I understand that breathwork is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and I will not use it in place of any form of therapy. I recognize that breathwork requires emotional, physical, and mental effort, exertion, and behavioral experimentation, on my part, which may cause physical, mental or emotional injury. I fully acknowledge and take full responsibility for all the risks involved. I understand that it is my responsibility to consult with my health care provider prior to participating in the session. In the event that I am injured, I agree to assume any financial obligation, either through my personal health insurance, or through some other means, for any medical costs I incur. Rise Up Shine Bright and Meagan Cole assume no responsibility for any medical expenses, injury, or damage suffered by me in connection with the use of any facilities or services in connection with the sessions. IN CONSIDERATION OF MY PARTICIPATION IN THE SESSIONS, I HEREBY GENERALLY RELEASE, AND PROMISE TO INDEMNIFY, DEFEND, AND HOLD HARMLESS RISE UP SHINE BRIGHT AND MEAGAN COLE, AND THEIR RESPECTIVE AGENTS AND EMPLOYEES (THE “RELEASE PARTIES”), FROM ANY LIABILITY WHATSOEVER. I will reimburse Rise Up Shine Bright and Meagan Cole for any damages, reasonable settlements and defence costs, including attorney’s fees, that they incur because of any such claims made against them. I agree that the terms of this agreement, including the indemnification obligations in this paragraph, will be binding on my estate, and my personal representative, executor, administrator or guardian will be obligated to respect and enforce them. This RELEASE does not extend to claims for gross negligence, intentional or reckless misconduct, or any other liabilities that applicable law does not permit to be excluded by agreement. I agree that the purpose of this agreement is that it shall be an enforceable RELEASE OF LIABILITY AND INDEMNITY as broad and inclusive as is permitted by Canadian law. I agree that if any portion or provision of this agreement is found to be invalid or unenforceable, then the remainder will continue in full force and effect. I also agree that any invalid provision will be modified or partially enforced to the maximum extent permitted by law to carry out the purpose of the agreement.I understand that this is a contract that affects my legal rights, and I have read and understood this form and all its contents, and I voluntarily agree to the terms and conditions stated above.To submit questions regarding this release please email: riseup.shinebright.ca@gmail.com *
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