Breathwork Registration Form

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Legal First & Last Name

Preferred Name

What date do you want to register for?

Dec. 8th – 9:30am – $ 75.00
Scholarship Option – see more below – $ 0.00

Workshops are non-refundable, however you can transfer your purchase to another individual OR another date if you end up being unable to attend.

I would like to register for a scholarship for the following session.

9:30am – Dec. 8th

Put N/A in credit card information if selecting scholarship option.

Payment Information

Name on Card

Credit Card Number

Expiration Date

3 or 4 digit CVV

Zip Code

Liability Release

I acknowledge that Somatic Release Breathwork™ is a deep and powerful process. I have notified the practitioners of any physical injuries, mental or psychological conditions I have. I engage in this experience willingly and take full responsibility for my own physical, mental and emotional experiences during and after the session.

Contraindications

Somatic Release Breathwork™ is intended as a personal growth experience and should not be looked upon as psychotherapy or a substitute for psychotherapy. It is not appropriate for pregnant women, for persons with cardiovascular problems, including angina or heart attack, high blood pressure, glaucoma, retinal detachment, osteoporosis, history of seizures, stroke, major psychiatric conditions, recent surgery, acute infectious illness or epilepsy. If you have any doubt about whether you should participate, please consult with your primary care physician. Persons with asthma should bring their inhaler and consult with their primary care physician.

Release

I hereby release and hold harmless Isaac Archuleta and iAmCouncil (DBA of iAmClinic) from any and all results that arise during or from the Somatic Release Breathwork. I waive all rights under law regarding the same. I or my representative(s) agree to full release and hold Isaac Archuleta and iAmCouncil (DBA of iAmClinic) harmless from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).

I also recognize that while completing Somatic Breathwork with Isaac Archuleta might be healing in and of itself, it does not constitute a therapeutic relationship for psychotherapy purposes.

Attestation of good health

I hereby confirm that I have read and understood the above information and attest that my general health is good to participate.

BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Signature