If you are currently experiencing any of the conditions below, the normal physiological changes that occur while practicing the Conscious Connected Breath and/or yogic pranayama could be potentially harmful to you or cause you distress. Please know you can participate in our offering if you have any of these conditions, but in order to keep you safe and healthy, it is your responsibility to breathe your natural nose breath as an alternative to the Conscious Connected Breath or yogic pranayama and/or respect your limitations with regard to physical postures and movement. If you would like me to be aware of your condition, please select from the list below. Please note that disclosing this information is optional, and while I will personally safeguard and not disclose this information to anyone, this google form is *not* HIPAA compliant.
If you suffer from of the above medical or uncontrolled psychiatric conditions, have you consulted your medical or psychiatric provider about the safety of participating in Conscious Connected Breathwork and/or yogic pranayama?
I understand that yoga and guided breathwork are: a) NOT intended to replace any relationship I have with my medical, psychiatric, and/or primary health care provider(s); b) NOT intended to constitute medical/psychiatric advice or any substitution for medical/psychiatric care; c) NOT to be relied on for recommendations, diagnosis, or treatment in relation to any health problem or disease. I understand and acknowledge that by participating in this breathwork and/or yoga session, I do so at my own risk. It is with this understanding that I voluntarily sign this waiver. Since the session is experiential and the extent of the session’s risks and benefits are not fully known, I agree to assume and accept full complete responsibility for any known and unknown risks associated with my participation in the session, including any physical injury, psychological or emotional effects, death, loss, or property damage. I, acting on behalf of myself, my heirs and my assigns, hereby release Robin Giacomo and Mandy Lax from any actions, causes of action, complaints, claims, damages, costs and expenses of any kind with respect to or arising out of any the discussions, consultations, and breathwork session(s) I have had or may have with Robin Giacomo and Mandy Lax now or in the future.
"I hereby grant permission to [Your Name/Company Name] to use any photographs taken of me during this session for website, marketing materials, or any other promotional purposes."
Thank you for regerstering!
