Your Name
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First Name
Last Name
Email
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Date of Birth
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MM
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Your Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
WAIVER PART 1
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RadiateZ warmly welcomes you to our sessions. Our sessions range from physical movement, exercise, breathing (including breath work), meditation, journaling, reflecting, Neuro linguistic programming (NLP), coaching, and the consumption of provided food, both liquids, and solids (referred to ‘Sessions’). As everyone comes to our Sessions for different reasons, please always let your facilitator know of any injuries or relevant medical information (including any level of fitness, health, nutrition, use of medication, medical history, current physical, mental or medical condition or any dietary restrictions), especially if you are new, if your situation has changed or if you have a new facilitator. RadiateZ and its facilitators priority is to ensure that all the Sessions are run safely and correctly by all participants. In order to do this, all participants must follow instructions from RadiateZ and its facilitators at all times. RadiateZ encourages you to stop whenever you need to. As a rule, ‘if it does not feel right then do not do it’. If you are unsure about whether a pose, movement or breathing / meditation instruction is right for you or you are feeling any dizziness, tingling, fainting and or weakness, please seek assistance from our facilitator. We are here to help you get the most from your practice and more than happy to offer adjustments or alternatives. Any suggestions or recommendations offered by RadiateZ or its facilitators during the course of our Sessions does not consistent medical advice and is only intended as an educational. For qualified medical advice, please consult a medical professional. We cannot assess the health risks particular to each individual participant. Please ensure you know your limitations, both physically and mentally, and act accordingly. *Please do not attend our Sessions if you have a heart condition or are pregnant. If you require additional assistance, please speak with a medical professional. *You are responsible for safeguarding your personal belongings and valuables during our Sessions. You should not bring any valuable personal property to our Sessions and RadiateZ takes no responsibility for any lost, stolen or damaged personal property.
WAIVER PART 2
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I understand that Sessions includes physical movement as well as an opportunity for relaxation, stress management and relief of muscular tension. As is the case with any activity such as these, the risk of potential for serious personal injury, including both physical and mental injury, or death is always present and cannot be entirely eliminated. If I experience any pain, discomfort, fatigue, nausea or any other symptoms, I will cease or adjust the posture or technique and ask for support from the facilitator. *Our sessions are not substitutes for medical attention, examination, diagnosis or treatment. Our Sessions are not recommended and is not safe under certain medical conditions such as heart conditions or pregnancy.
WAIVER PART 3
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I affirm that I alone am responsible to decide whether to practice at RadiateZ. If my health condition should change I agree to fill out a new Waiver of Liability form and advise the facilitator. I am not pregnant and consent to receive first aid and medical treatment by RadiateZ in the event of an accident, injury or illness during a Session. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against RadiateZ and its facilitators.
Emergency Contact
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Ie: Mother (Full name)
First Name
Last Name
Emergency Contact Phone Number
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(###)
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Are you currently healthy?
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Do or did you suffer from one of the following conditions:
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Please tick from the below boxes
Do you currently use medication?
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Are you allergic to a a certain substance?
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IE: Food / Environment ?
Are you currently pregnant OR wish to become pregnant in next 6 months?
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By ticking this box I hereby declare to have filled out this form truthfully.
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Date of Acknowledgment
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MM
DD
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