$12.00 USD

Date

Emergency Contact Name

Emergency Contact Number

Your Physician's Name (if applicable)

Your Physician's Contact Number (if applicable)

Have you ever done breathwork prior to this program?

If so, when? And with whom? What was your experience like?

Do you have any traumatic experiences or any other information you would like me to be aware of? If yes, please explain.

Have you been hospitalized in the last 12 months?

If yes, please explain:

Is there any emotional or physical reason you may not be a good candidate for breathwork? If so, please explain.

Have you had OR do you presently have any of the following conditions? (Check if yes.)

If you selected Other, please specify here:

If you have answered “Yes” to one or more of the above questions, you must consult your physician before engaging in meditative breathwork. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

By signing here you attest to the truthfulness of your statements and answers. We reserve the right to determine eligibility for engagement and participation in our program based upon the answers given.

Printed Name

Today's Date

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I have read and agree to the terms and conditions of this page as follows:

I agree that my participation in the Breathwork Sessions 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 Breathwork Sessions, is neither the responsibility nor Breathwork Sessions of Lila Heller or trained Facilitator.

I understand that during the Breathwork Sessions, I may be photographed or videotaped for quality training purposes. We promise to take utmost care of any footage of you and will pledge that this footage will only be used for internal training purposes and not distributed in any way, within the boundaries of the law that applies to this agreement. If for whatever reason we wish to use footage outside of training purposes, we will inform you and get your permission first. By signing this agreement, you agree to these terms.

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 Breathwork Sessions.

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. Lila Heller assumes 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 Breathwork Sessions.

IN CONSIDERATION OF MY PARTICIPATION IN THE BREATHWORK SESSIONS, I HEREBY GENERALLY RELEASE, AND PROMISE TO INDEMNIFY, DEFEND, AND HOLD HARMLESS LILA HELLER, AND THEIR RESPECTIVE AGENTS AND EMPLOYEES (THE “RELEASE PARTIES”), FROM ANY LIABILITY WHATSOEVER. I will reimburse Lila Heller for any damages, reasonable settlements and defense 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 California 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: [email protected]

The Breathing Room Virtual Workshop

This upcoming midsummer breathwork session will focus on rest and easing into sleep.

Each session includes journaling, breathwork and short discussions. Learn the benefits of breathwork, techniques to incorporate into your daily practice AND how to feel at home in your body.