| Leave Dysfunction Junction Behind! 3rd Release and Disclosure
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Release & Disclosure
“Leave Dysfunction Junction Behind!”
I acknowledge that on May 4th through May 6th, 2012 in the State of Washington I am voluntarily participating in a workshop/retreat given by Sophia (Carrie) Cayer, the Personal Peace Foundation and Spirals.
In consideration for being permitted to attend the workshop, I hereby waive, release and discharge any and all claims of damages for personal injury or property damage which I may have, or which may hereafter accrue to me, as a result of my participation in the workshop. This release is intended to discharge in advance Sophia and the persons who assist her at the workshop and their respective agents and employees from and against any and all liability arising out of or connected in any way with my participation in the workshop, even though that liability may arise in whole or part out of negligent acts or omissions or carelessness on the part of those persons. I further understand that serious emotional and physical distress is sometimes experienced by persons participating in the workshops, and that I should not participate unless I am willing to assume the risk that I may experience such distress.
Knowing the risks, I nevertheless hereby agree to assume those risks and to release and hold harmless all of the persons or entities mentioned above who (through negligence, carelessness or otherwise) might be liable to me, or my heirs or assigns, for damages. It is further understood and agreed this waiver, release and assumption of risks is to be binding on my heirs and assigns.
Further, portions of this workshop may be audio and/or videotaped and photos may be taken by Sophia, the Personal Peace Foundation or Spirals and I hereby give my consent and permission for my image and voice to be recorded and included in any audio or video product, or related written materials that Sophia or the Personal Peace Foundation may produce and/or sell to the public or use for publicity purposes, without prior notice to me, as they see fit.
The techniques that will be taught by Sophia at the workshop are experimental. While there are theories as to how they work, why they work, and why they sometimes don't work, there is just the beginning of accepted scientific explanation available. As a result of their experimental nature, Sophia does not know with certainty in advance whether someone can be helped or if the techniques will help a particular person with a particular problem. In the past, some attendees have become very intense and temporarily experienced heightened emotional and physical distress during the process. While assistance will be available should such an event occur, there is no assurance that the assistance will be successful or bring relief and I agree that while this assistance may be made available in a good faith by volunteers, I hereby assume full responsibility for my emotional and physical health and hold Sophia and any such volunteer harmless and blameless from any claim by me, including any claim for negligence, if for any reason they are unable to successfully assist me. My attendance at the workshop, my use of the techniques and my acceptance of the help of any such volunteer will be completely voluntary on my part and with full awareness that no one at the workshop is responsible for my emotional and physical well-being except me.
I agree that my emotional and physical health is my responsibility. I further recognize that Sophia is not a physician and holds no licensing or credentials of any kind in the medical healing professions. Accordingly, I assume and accept the risk of any and all adverse outcomes that might result from this experimental procedure and from attending the workshop or using the techniques taught at the workshop. Sophia does not recommend that I, or any person with whom I may use the techniques, stop using any prescribed medicine or other therapy that I or he/she may be using, without consulting a qualified physician, even if the techniques appear to indicate that such medicine or therapy is unnecessary. These techniques are not intended to be a substitute for any therapy or treatment that I may presently be using with licensed physicians or psychologists.
By signing this document, I agree that (1) I have not modified this form from its original and (2) neither Sophia, the Personal Peace Foundation, Spirals, nor any assistant or volunteer will have any liability to me for any damage whether to my emotional or physical health or otherwise arising in any way whatsoever out of my attendance at the workshop or my use of the techniques.
I further acknowledge that I have read the following disclosure put forward by Sophia. Disclosure
Each client will be interviewed and/or informed of the nature of their practices and if it is determined that their services can be of benefit, Sophia Cayer will provide services in accordance with the education, training and/or years of experience she has.
They offer the following services and have the following education, training, experience and other qualifications regarding the services provided.
Sophia (Carrie) Cayer makes the following disclosures.
Sophia is an ordained minister, Reiki Master and personal performance coach. She is not a licensed medical professional, physician or psychologist.
Each client will be interviewed and/or informed of the nature of her practices and if it is determined that her services can be of benefit, Sophia Cayer will provide services in accordance with the education, training and/or years of experience she has.
She offers the following services and has the following education, training, experience and other qualifications regarding the services provided.
Ministerial, Pastoral Counseling or Intuitive Spiritual Counseling. Ordained minister with the Universal Church of Life on August 1996. Emotional Freedom Techniques, EFT Master designation, EFT Honors Cert, Basic CC and Advanced CC, created and founded by Gary Craig. Extensive study of EFT DVD courses and attendance of many workshops offered through EFT and Gary Craig. One-on-one EFT sessions and workshop presentations for more than eleven years. AAMET (Association for Advancement of Meridian Techniques) Trainer of Trainer status.
I understand and accept all provisions in this Release & Disclosure document.
Signature: _________________________________________Date: _____________________
Print Name:_____________________________________________________
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