Name *

First Name

Last Name

Phone *

(###)

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Contraindications: *

Please carefully review the following list of conditions. It is important to confirm that you do not have any of the conditions listed below: Severe mental health conditions (e.g., bipolar disorder, schizophrenia, psychosis) Cardiovascular problems or a history of heart disease History of seizures or aneurysms Severe asthma Hospitalisation for any psychiatric condition, emotional crisis, or spiritual emergence within the last 3 years Recent surgery Recent injuries or fractures Heavy medications that alter brain chemistry Diagnosed with severe PTSD Any other medical, psychiatric, or physical conditions that may impair or affect your ability to engage in activities involving intense physical and/or emotional release
.

I confirm I do NOT have any of the above conditions.

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone No. *

(###)

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Photo/Video Release: *

If you are comfortable, we may take photos or videos during the session for promotional purposes. Please indicate your preference below:

I consent to being photographed or filmed during the session for promotional purposes.

I do not consent to being photographed or filmed during the session.


Disclaimer: *

By attending this session, you certify that you have read and agreed to the following disclaimer. Your session may involve physical movements and energetic work, which carry inherent risks. Please Note: The risk of injury, including disabling, severe, or fatal injuries, is always present in any physical activity and cannot be entirely eliminated. If you experience any pain or discomfort during the session, you are instructed to discontinue the activity and seek support from the facilitator. It is essential to continue breathing smoothly throughout the session. You assume full responsibility for any damages or injuries that may occur during participation in this event. This energy work is not a substitute for medical or psychological attention, examination, diagnosis, or treatment. These sessions are not recommended or safe for individuals prone to mania, delusion, or psychosis. By registering for this class, you affirm that you are in good health and physical and mental condition to participate in this program. Additionally, you agree to inform the facilitator of any medical conditions or physical limitations prior to the session. This process is not recommended for individuals who are pregnant. Respect for Others' Privacy: I understand and agree to respect the privacy of all participants in this session. Any personal information or experiences shared by others during the session will be treated with confidentiality and will not be disclosed outside of this space. I commit to creating a safe and respectful environment for everyone involved. Participant Acknowledgment I, the Participant, voluntarily choose to participate in the event today with Cate Porter and accept full responsibility for my own physical, mental and emotional well-being. I agree with the terms of this disclaimer.

I agree

Date Signed *

MM

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Event Date *

MM

DD

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