Release, waiver of liability, and indemnity agreement for participation in event or activity Use this waiver when the breathwork session is facilitated by Jessica Jorgen and Jason Posey Name of Releasor * First Name Last Name Email * In exchange for participation in Breathwork ceremony or session (the “Activity”), organized by Jessica Jorgen and Jason Posey (“Releasee”), I hereby agree as follows: * 1. I and anyone claiming on my behalf release and forever discharge Releasee and its affiliates, successors and assigns, officers, employees, representatives, partners, agents and anyone claiming through them (collectively, the “Released Parties”), in their individual and/or corporate capacities from causes of action of any nature and kind, known or unknown, which I may have against Releasee or any Released Parties arising out of or relating to any injury, loss or damage to person and property that may be sustained as a result of participation in the Activity (“Claims”). 2. I understand that participation in the Activity involves inherent risks, including risk of physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent paralysis and/or death, and I assume all related risks and voluntarily participate in the Activity. Yes, I understand MEDICAL DISCLAIMER & CONTRAINDICATIONS. * I understand that breathwork and Activities may involve strong connected breathing, which can result in dramatic experiences accompanied by strong emotional and physical responses. I understand that I may find the Activities physically, emotionally, or mentally stressful, and that breathwork and Activities are not safe under certain medical conditions and not advised for all persons I hereby state that I am not pregnant, and if any of the above conditions apply to me, I will advise the Facilitator prior to participation. I understand that the Facilitator is not qualified to evaluate my fitness for involvement in the Activities, and that I am fully responsible for seeking medical help to treat all symptoms that are present before and after the Activities. I hereby state that I am physically and mentally fit to participate in Activities, and understand that it is solely my responsibility to seek professional support after Activities if I feel unstable mentally or emotionally. I knowingly waive any claim I may have against the Releasees for injury or damages that I may sustain as a result of participating in Activities. RISKS. I understand and acknowledge that the Activities in which I am participating in bear certain known inherent risks that contribute to the unique character of these Activities, and that Facilitator cannot eliminate, alter, or control these inherent risks. “Risks” include, but are not limited to, known and unknown health conditions, inaccessibility to immediate medical attention, risks inherent in breathwork that include, but are not limited to, over-exertion, psychological distress and disorientation, hyperventilation, respiratory alkalosis, muscle spasms, chest pain, numbness, heart attack, death, and injury or death caused by negligence on the part of Participant or other people around Participant. Yes, I hereby expressly and specifically assume the risk of injury or harm, and agree that my involvement in Activities is purely voluntary, and that I elect to participate in spite of the Risks. Contraindications * Please check all that apply Pregnant Cardiovascular disease or prior heart attack Epilepsy High blood pressure Eye conditions such as glaucoma or detached retina Personal or family history of aneurysms None of the above If answered YES to any of the above conditions, please explain * Are there any other medical conditions or concerns your facilitator should be aware of? * * 3. I agree to indemnify Releasee against any and all claims, actions, lawsuits, damages and judgments, including attorney’s fees, arising out of or relating to my participation in the Activity. 4. This Release for Participation in Event or Activity (“Release”) shall not be in any way construed as an admission by the Releasee that it has acted wrongfully with respect to me or any other person, that it admits liability or responsibility at any time for any purpose, or that I have any rights whatsoever against the Releasee. 5. This Release shall be binding upon the parties and their respective heirs, administrators, personal representatives, executors, successors and assigns. I have the authority to release the Claims and have not assigned or transferred any Claims to any other party. The provisions of this Release are severable. If any provision is held to be invalid or unenforceable, it shall not affect the validity or enforceability of any other provision. This Release constitutes the entire agreement between the parties and supersedes any prior oral or written agreements or understandings between the parties concerning the subject matter of this Release. This Release may not be altered, amended or modified, except by a written document signed by both parties. The terms of this Release shall be governed by and construed in accordance with the laws of the State of Washington Yes, I have carefully read and fully understand all the provisions of this Release and am freely, knowingly and voluntarily entering into this Release. Emergency contact information * First Name Last Name Emergency contact phone number * Country (###) ### #### Relationship to participant * I certify that I am 18 years of age or older * Yes No By submitting this agreement, I certify that all the information included in this agreement is true and complete. * Type full name Date * MM DD YYYY Thank you!