Name(Required) First Last Mobile Phone(Required)Emergency Contact - Name and Number(Required) Please fill in your age(Required) Have you participated in any form of conscious breathwork before? If yes, where and with whom?(Required)What brings you to engage in this process at this time?(Required)Do you have any concerns or questions about participating in this event?Please select if you have been hospitalised for any of the following:(Required) Cardiovsacular disease or heart attack Diagnosed Psychiatric condition HIV+ High Blood Pressure Epilepsy Osteoporosis Seizure Family history of strokes Glaucoma or retinal detachment Headaches Aneurism Diabetes Recent Surgery Asthma (if yes, bring inhaler to breath work session None of the above Are you taking any medications that will effect you today? If so, please specify:(Required) No Yes Are you currently in therapy of a support group?(Required) No Yes Where there any complications with your birth? Ie: Caeserian, anaesthesia, multiple births:Have you ever attempted or seriously considered suicide?(Required) No Yes Signature(Required) Reset signature Signature locked. Reset to sign again I hereby confirm that I read and understood the above information and have answered all questions completely and honestly, and have not withheld any information. My general health, other than as noted is good. I will not use alcohol or recreational drugs during this experience.I agree to not to hold the Breath Sanctuary, as well as the teachers of the breath work experiences, and assistants against all loss, damage, liability or expense arising out of, or in connection with anything owned or controlled by the Breath Sanctuary, or resulting from any acts, failure to act, or negligence of the Breath Sanctuary. The Breath Sanctuary is not liable for any slips, falls or injuries while on the premises of the breath work or ice bath experience. The Breath Sanctuary are not liable for any physical, medical or emotional experiences that may occur, however please notify someone immediately should something happen during the experience. I agree that use of the premises, facilities and equipment of the Breath Sanctuary is accepted by me at my own risk, and that the Breath Sanctuary is absolved and discharged from all liability for any loss or damage I may incur of my personal property.Name(Required) First Last Date(Required) DD slash MM slash YYYY
