Breathwork Waiver and Release of Liability
Mindful Way Studio, Mokena
Effective Date: January 22nd, 2025
Breathwork sessions at Mindful Way Studio are designed to promote relaxation, self-awareness, and personal growth. While these sessions are generally safe for most participants, they may involve physical, emotional, or psychological responses. By signing this waiver, you acknowledge and accept the potential risks associated with breathwork and release Mindful Way Studio and its facilitators from liability.
1. Participant Acknowledgment
By signing this waiver, you acknowledge and agree to the following:
- Voluntary Participation: I am voluntarily choosing to participate in breathwork sessions at Mindful Way Studio.
- Health Considerations: I understand that breathwork may involve physical and emotional exertion. I confirm that I am in good health and have consulted with a healthcare professional, if necessary, to ensure it is safe for me to participate.
- Pre-Existing Conditions: I have disclosed any medical conditions, including but not limited to respiratory or cardiovascular issues, epilepsy, mental health conditions, or pregnancy, to the facilitator prior to participation.
- Personal Responsibility: I understand that I am responsible for monitoring my own physical, emotional, and mental well-being during the session. If I experience discomfort, I will stop and inform the facilitator immediately.
2. Potential Risks
I understand that breathwork may involve risks, including but not limited to:
- Dizziness or lightheadedness.
- Emotional releases or unexpected feelings.
- Physical discomfort or shortness of breath.
I acknowledge that these risks, while generally minimal, may vary depending on my personal health and readiness to participate.
3. Release of Liability
I hereby release, discharge, and hold harmless Mindful Way Studio, its owners, facilitators, staff, and affiliates from any and all liability, claims, or demands arising out of or connected with my participation in breathwork sessions, including but not limited to:
- Physical injury or harm.
- Emotional distress or psychological responses.
- Loss or damage to personal property.
This release is binding upon me, my heirs, and legal representatives.
4. Confidentiality
I understand that all information shared during breathwork sessions is confidential. Mindful Way Studio will protect my privacy and will not disclose any personal information without my explicit consent, except as required by law.
5. Informed Consent
I acknowledge that the facilitator has explained the nature of breathwork sessions, including potential risks and benefits. I understand that I may decline to participate in any exercise or end my session at any time.
6. Media Consent
Mindful Way Studio occasionally uses photography or video recordings for promotional purposes. By checking the box below, I consent to being photographed or recorded during sessions:
[ ] I consent to the use of my image or likeness for promotional purposes.
[ ] I do not consent to being photographed or recorded.
7. Agreement
By signing below, I confirm that I have read, understood, and agreed to this Breathwork Waiver and Release of Liability. I fully accept the terms and voluntarily assume all risks associated with participation.
Participant Name (Printed): _________________________________
Signature: _______________________________________________
Date: _______________________
Emergency Contact Name: _________________________________
Emergency Contact Phone Number: _________________________
Facilitator Name (Printed): ________________________________
Facilitator Signature: _____________________________________
Contact Information
Mindful Way Studio
11600 Francis Rd, Unit C-2, Mokena, IL 60448
708-436-4493
contact@mindfulwaystudio.com
This form is intended to ensure a safe and transparent experience for all participants. For questions or further clarification, please contact us directly.