Name
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First Name
Last Name
Email
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Phone
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Todays Date
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Release of Liability
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As the client, and in consideration for my participation in sessions with Katie Graham LLC and the facilitator Katie Graham. 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 Katie Graham LLC. I recognize that somatics 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. Katie Graham LLC 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 Practicum.
In considerations of my participation, I hereby generally release and promise to indemnify, defend, and hold harmless Katie Graham LLC and Katie Graham and their respective agents and employees, from any liability whatsoever. 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 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.
Emergency Contact Name
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First Name
Last Name
Emergency Contact Phone
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Do you presently have any of the following conditions? (Check if yes.)
Choose as many as applies
Elaborate on any health concerns or conditions, or if you clicked "Other" please explain :
If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in breathwork. Please seek advice from your physician on what type of activity is suitable for your current condition.
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Printed Name. By signing here you attest to the truthfulness of your statements and answers.
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Typed Signature
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