INFORMED CONSENT & LIABILITY WAIVER

By submitting this form, you acknowledge you have read, understood and agreed to the following:  

INFORMED CONSENT & LIABILITY WAIVER  I hereby consent to engage voluntarily in exercise, movement, and breathwork programs led by certified virtual and in-person instruction from trainers at The Mirror Impact, LLC. I understand that the activities may be strenuous and may require me to engage in body movement and breathing practices that I am not familiar with in order to improve overall fitness and wellbeing. By submitting this form, I affirm that I have read, understood, and agreed to this document in its entirety.  

BREATHWORK PARTICIPATION: I confirm that I am in sound physical and mental health, and that I do not have a history of any condition that would hinder my participation in Breathwork activities. Conditions that may be contraindicated include, but are not limited to: cardiovascular conditions including uncontrolled, high, or abnormal blood pressure; history of aneurysm, heart attack, or stroke; heart disease; uncontrolled thyroid conditions; uncontrolled diabetes; epilepsy or history of seizures; severe asthma; glaucoma; detached retina; osteoporosis; recent surgery; diagnosed severe PTSD; severe mental health conditions such as psychosis, schizophrenia, or bipolar disorder; any person with mental health concerns who is not in treatment or lacks adequate support; any person experiencing an emotional or spiritual crisis; or pregnancy. If you have a question about a condition not listed above, we recommend consulting a physician before beginning Breathwork. I acknowledge that Breathwork is not a substitute for medical or psychological diagnosis, treatment, or therapy. Any suggestions or guidance provided by the facilitator are not intended as medical treatment. I am encouraged to consult with a qualified healthcare professional regarding any physical or mental health concerns. I am aware that Breathwork is a holistic healing modality that involves conscious regulation of breath, including deep and rhythmic patterns that could temporarily lead to physical sensations such as tingling, light-headedness, dizziness, or muscle tension. I understand that Breathwork can result in intense physical, mental, emotional, energetic, and psychological experiences. I take full responsibility for my participation and integration, and I acknowledge that I am responsible for seeking appropriate professional support if needed following any session. I understand that any physical touch during sessions is optional, consensual, and can be declined or withdrawn at any time. 

RISKS & ACKNOWLEDGMENTS: I have obtained my doctor's consent to begin this class/program, or I have chosen to willingly participate without my doctor's written consent, accepting full responsibility for doing so. I have informed my trainer of any pre-existing conditions or injuries prior to beginning any exercise or breathwork program. I understand that during participation I will be asked to complete physical activities unless symptoms such as fatigue, shortness of breath, chest discomfort, or similar occurrences appear. At that point, it is my complete right — and obligation — to decrease or stop and inform program staff of any symptoms. I am responsible for monitoring my own condition throughout sessions and communicating any limiting conditions to my trainer. I have been informed that there exists the remote possibility during exercise of adverse changes including, but not limited to, abnormal blood pressure, fainting, dizziness, disorders of heart rhythm, and in very rare instances, heart attack, stroke, or even death. I further understand that there exists the risk of bodily injury including, but not limited to, injuries to the muscles, ligaments, tendons, and joints. Fully understanding these risks, it is my desire to participate as indicated herein. 

RELEASE OF LIABILITY: In consideration of being permitted to participate in The Mirror Impact programs, I hereby voluntarily release, waive, discharge, and agree not to hold liable The Mirror Impact, LLC, Ariele Keller, and any affiliates, contractors, employees, or volunteers from any and all liability, claims, demands, actions, or causes of action arising out of or related to any loss, damage, injury, or death that may be sustained while participating in any activity, whether caused by negligence or otherwise. I agree to indemnify and hold harmless The Mirror Impact, LLC and its representatives from any loss, liability, damage, or costs, including attorney fees, that they may incur due to my participation in this program, whether caused by negligence or otherwise.  

ACKNOWLEDGMENT:  By signing below, I acknowledge that I have read this Informed Consent & Liability Waiver in its entirety, that I understand its terms, and that I agree to be bound by them. I confirm that my participation is voluntary and that I am signing this agreement freely and without duress.