Liability Waiver & Release (Sound & Acupuncture)

LIABILITY WAIVER & RELEASE

1. Participation. I, the undersigned, wish to participate in Sessions by Divine Danelle, an Arizona Limited Liability Corporation (“Hosting Company”).

2. Assumption of Risks. I wish to participate in the Sessions at the Location, and hereby assume all risks of engaging in the Sessions. I also hereby hold harmless and release Hosting Company, its members, managers, employees and agents, as well as Danelle Girard in her individual capacity (Indemnitees) and indemnify each of them from and against any and all loss, claim, cause of action, lawsuit, damage, liability, cost or expense whatsoever which any of them may incur arising out of or in connection with my participation in the Sessions at the Location, including but not limited to the personal development and transformational activities to be conducted as part of the Sessions; food and beverages served at the Location; and the use of facility at the Location.

3. Waiver. I hereby certify that I am at least 18 years of age (or, if less than 18 years of age, have caused this Liability Waiver and Release to be signed by my parent or legal guardian), I agree that neither I nor any member of my family will sue any Indemnitee because of my participation in the Sessions or my presence at the Location at any time, and I understand that this Release shall be binding upon my estate, my heirs, next of kin, executors, administrators, representatives, successors and assigns. I specifically waive any claim or right to assert any cause of action or alleged case of action or claim or demand which has, through oversight or error intentionally or unintentionally or through a mutual mistake, been omitted from this Liability Waiver and Release.

4. Covenants Regarding Participation in Retreat. I further agree:

• To fully release and hold harmless Danelle Girard from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my sessions;

• To pay in full at or before the commencement of the Sessions all fees, charges and expenses charged by Hosting Company for the Sessions;

• To pay in full before the end of the Sessions all charges and expenses that I have incurred while a guest at the Location;

• To be financially responsible for any and all damage that I may cause while at the Location, including but not limited to light fixtures, walls, windows, doors, and cars, it being understood that my right to use the Location may be terminated permanently at the sole discretion of Hosting Company if I commit any violent acts while on the Location premises whether intentionally or negligently;

5. Representations Regarding Psychological Stability. I understand that the Sessions is a nondenominational spiritual activity and should not be treated as psychotherapy or psychological counseling even though the Sessions will feature activities designed to teach me personal development and transformational skills I can use for my personal growth. These activities may involve accessing sensitive psychological material, for example childhood memories or personal traumas, and I declare that I have the psychological stability to handle whatever may come up. I understand that I am responsible for my participation in the Sessions and any personal development or psychological work or conditioning that I choose to do, and I will not hold Hosting Company or Danelle Girard responsible for any pain, emotional suffering or damages that may occur.

6. Disclosures Regarding Medical and Psychological Conditions. Even though the Sessions and its activities aren’t intended as psychotherapy or psychological counseling, the work I will be learning to do can access deep places inside me. I have fully disclosed to Hosting Company any and all medical or psychological conditions, food allergies, dietary restrictions, and other circumstances that may prevent me from fully participating in the Sessions at the Location.

7. Additional Acknowledgements. I further understand that information I may receive as part of the Sessions is in no way intended as medical or dietary advice, as a substitute for medical or dietary counseling, or as treatment or cure for any particular health condition.

8. Governing Law; Amendment; Interpretation of Agreement. This Liability Waiver and Release shall be governed by the laws of the State of Arizona, and that any action, claim or proceeding under this Liability Waiver and Release shall be commenced exclusively in the courts of Arizona or the United States District Court. This Liability Waiver and Release may not be revoked, terminated or amended verbally, but only by a written instrument signed by me and an authorized representative of Hosting Company. All covenants contained herein are severable, and in the event of any being held invalid by any competent court, this Agreement shall remain intact except for the omission of the invalid covenant.

BY AGREEING TO THIS DOCUMENT, YOU WILL WAIVE LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE DIVINE DANELLE, LLC.

I HAVE READ AND UNDERSTOOD THIS LIABILITY WAIVER AND RELEASE, HAVE HAD THE OPPORTUNITY TO HAVE LEGAL COUNSEL REVIEW THIS LIABILITY WAIVER AND RELEASE, AND I AM AWARE THAT BY SIGNING THIS LIABILITY WAIVER AND RELEASE I AM WAIVING CERTAIN LEGAL RIGHTS WHICH I OR MEMBERS OF MY FAMILY, MY HEIRS, NEXT OF KIND, EXECUTORS, ADMINISTRATORS, REPRESENTATIVES, SUCCESSORS AND ASSIGNS MAY HAVE AGAINST DIVINE DANELLE, LLC, ITS MEMBERS, MANAGERS, EMPLOYEES AND AGENTS.

ACUPUNCTURE INFORMED CONSENT TO TREAT

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist, Luna Acupuncture, and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist, Luna Acupuncture, including those working at the clinic or office listed below or another office or clinic.

I understand that methods of treatment for this session includes acupuncture. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needle insertion site. It may last a few days and dizziness or fainting, nerve pain, pneumothorax or organ puncture. Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment.

I understand that while this document describes the major risks of treatment, other side effects and risks may occur.

While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment I expect the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known is in my best interest.

I understand the clinical and administrative staff may review my patient records, but all my records will be kept confidential and will not be released without my written consent.

By voluntarily agreeing to this document, Is how that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my condition.