Waiver of Liability & Consent for Treatment

IN CONSIDERATION OF the risks that exist while participating in SOUND HEALING ENERGY SESSIONS (hereinafter the “Activity”) due to having received experimental treatments; and

IN CONSIDERATION OF my desire to participate in said Activity and being given the right to participate in same;

I HEREBY, for myself, my heirs, executors, administrators, assigns or personal representatives (hereinafter collectively, “Releasor”, “I” or “me”, which terms shall also include Releasor’s parents or guardian if Releasor is under 18 years of age), knowingly and voluntarily enter into this Agreement and hereby waive any and all rights, claims or causes of action of any kind arising out of my participation in the Activity; and

I HEREBY release and forever discharge SUSAN E. SEIDMAN, HOLISTIC HEALTH PRACTITIONER, office located in Morrisville, North Carolina 27560, her affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns (collectively “Releasees”), from any injury or side effect that I may suffer as a direct result of my participation in the aforementioned Activity.

I AM VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED ACTIVITY AND I AM PARTICIPATING IN THE ACTIVITY ENTIRELY AT MY OWN RISK. I AM AWARE OF THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS ACTIVITY, WHICH MAY INCLUDE UNKNOWN SIDE EFFECTS FROM HAVING PREVIOUSLY RECEIVED EXPERIMENTAL INJECTION(S).  I ASSUME ALL RELATED RISKS, BOTH KNOWN AND UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY.

I HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS DOCUMENT AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY AND CONSENT FOR TREATMENT.  I EXPRESSLY AGREE TO RELEASE AND DISCHARGE Susan E. Seidman, Holistic Health Practitioner, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST SUSAN E. SEIDMAN FOR PERSONAL INJURY.

I agree that this document shall be governed for all purposes by North Carolina law, without regard to any conflict of law principles.

THIS WAIVER AND CONSENT FOR TREATMENT SHALL REMAIN IN EFFECT FOR THE DURATION OF MY PARTICIPATION IN THE ACTIVITY, DURING THIS INITIAL AND ALL SUBSEQUENT EVENTS OF PARTICIPATION.

THIS AGREEMENT was entered into at arm’s length, without duress or coercion, and is to be interpreted as an agreement between two parties. Both the Participant and Susan E. Seidman acknowledge that this agreement is clear and unambiguous as to its terms, and that it will be interpreted based on the language in accordance with the purposes for which it is entered into.

In the event of an emergency, please contact the following person(s) in the order presented:

Emergency Contact:

Contact Relationship:

Contact Telephone:

I, THE UNDERSIGNED PARTICIPANT, AFFIRM THAT I AM OF THE AGE OF 18 YEARS OR OLDER, AND THAT I AM FREELY SIGNING THIS AGREEMENT. I CERTIFY THAT I HAVE READ THIS AGREEMENT, THAT I FULLY UNDERSTAND ITS CONTENT AND THAT THIS AGREEMENT CANNOT BE MODIFIED ORALLY. I AM AWARE THAT THIS IS A CONTRACT AND THAT I AM SIGNING IT OF MY OWN FREE WILL.

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(Participant’s Name – Printed)                                           (Date)

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(Participant’s Signature)