Breathwork Northwest Registration Registration Form Oct 24 Step 1 of 5 20% Workshop you are registering for:*Friday October 24, 2025Acknowledgement of Risk and Liability WaiverName* First Last Best contact email* Enter Email Confirm Email Hiddenlabel I will be fully vaccinated with FDA-approved vaccines for COVID-19 two weeks or more before arrival. Or I can provide documentation of a recent COVID-19 recovery. Below is a photo of my vaccine card or documentation of recent COVID-19 infection. HiddenCopy of Vaccination Card or Documentation of Recent InfectionAccepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 128 MB.Agreements (check all) required* I agree that if I show symptoms of COVID-19, or any infectious respiratory disease, I will not attend the workshop. If I develop any symptoms during the workshop I will notify a workshop facilitator and I will follow all instructions from BNW staff. Hidden* I agree to take extra covid precautions in the days before the workshop and, upon arrival, I agree to stay onsite for the entire event for which I am registered. * In order to protect the most vulnerable in our community, I agree to administer a COVID-19 Quick Test the morning of the event and will only attend if the result is negative. Waiver Statement (check all) required* I acknowledge the contagious nature of COVID-19 and other infectious respiratory diseases. Although Breathwork Northwest and the venue have put in place preventative measures to reduce the spread of disease, I understand that my participation in this event could lead to exposure or infection. Hidden* I further acknowledge that Breathwork Northwest and the venue have put in place preventative measures to reduce the spread of infectious respiratory disease. Hidden* I further acknowledge that Breathwork Northwest cannot guarantee that I will not become infected with any infectious respiratory disease. Hidden* I understand that the risk of being exposed to and/or infected by the COVID-19 virus can result from the actions, omissions, or negligence of myself and others, including but not limited to BNW staff and other participants. * I hereby release and agree to hold harmless Breathwork Northwest (BNW) from, and waive on behalf of myself, my heirs and personal representatives, any and all cause of action, claims, demands damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act, by BNW with respect to any bodily injury, illness, death, medical treatment or property damage that may arise from, or in connection to, my attendance and participation at events with BNW. This liability waiver and release extends to Breathwork Northwest together with all owners, partners, employees and contractors. Medical Form: Your Health and Well-being Welcome! To ensure your safety, and provide the best possible support, we need some medical information about you. Holotropic Breathwork® can be a powerful experience for personal growth, but please be aware that it is not a replacement for psychotherapy. The process can lead to intense emotional and physical release so this workshop may not be safe/appropriate for pregnant women, or for persons with cardiovascular problems, severe hypertension, severe mental illness, recent surgery or fractures, acute infectious illness, or epilepsy. Please answer the following questions as completely as you can. All information you share is strictly confidential and will only be used by your facilitation team in order to support you. If you answer "yes" to any question, but are not comfortable explaining the details on this form, simply write "Please contact me" in the description box and a facilitator will call you privately.I understand that this Holotropic Breathwork workshop is intended as a personal growth experience and should not be used as a substitute for psychotherapy or other mental health treatment.* I understand I don't understand If you answered "I don't understand," please contact us at admin@BreathworkNorthwest.org to clarify or discuss.I understand that Holotropic Breathwork could involve dramatic experiences accompanied by strong emotional and physical release.* I understand I don't understand If you answered "I don't understand," please contact us at admin@BreathworkNorthwest.org to clarify or discuss.Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Best Contact Phone* Emergency Contact Name* Emergency Contact Phone* Do you have a past history of, or currently suffer from any of the following:(These issues do not necessarily preclude attendance to the workshop, but it is important that we discuss them with you prior to attending.)High blood pressure* Yes No Please describe your typical blood pressue reading. Are you under medical care for high blood pressure?*Cardiovascular disease including heart attacks:* Yes No Please describe. Do you have any physical limitations?*Recent Surgeries?* Yes No 1. When did you have surgery?; 2. What type of surgery was it?; and 3. To what degree are you currently physically limited from it?*Past or recent physical injuries which are currently affecting you (including fractures/dislocations)* Yes No Please describe the injury and the physical limitations it causes.*Osteoporosis* Yes No Please describe any physical limitations or particular areas of concern.*Recent or current infectious or communicable diseases* Yes No Please describe.*Epilepsy* Yes No Please describe. Also, when was your last seizure?*Glaucoma or Retinal Detachment* Yes No Please explain*Asthma* Yes No Please describe. [Note: If you have a history of asthma, please bring your inhaler to the workshop.]*Are you currently pregnant?* Yes No What is your anticipated due date?* Have you been hospitalized for medical reasons in the past 20 years?* Yes No 1. When were you hospitalized?; 2. For what reason?; and 3. To what degree are you currently physically limited from it?*Have you ever been hospitalized or treated for an emotional crisis or for psychiatric reasons? (Including such things as mental illness, severe depression, suicidal thoughts or an attempted suicide, a psychotic episode, a nervous breakdown, etc.)* Yes No Note: These issues do not necessarily preclude attendance to the workshop, but it is important that we discuss them with you prior to attending.Please describe.*Are you currently taking any medications?* Yes No Please list medications and condition being treated.*Are you currently in therapy or involved in any form of support group or practice?* Yes No Please describe.*Is there anything else about your physical or emotional status you would like us to be aware of? Have you attended a BNW event in the past?* Yes No Would you like the chance to attend the introductory Zoom call and/or schedule a check in call with a facilitator before the workshop?* Yes No Have you ever attended a breathwork workshop of any type prior to this? If so, what type of breathwork? And, how was it for you?*Could you share a little about what you are hoping to get out of this experience?*Do you have any other practices/activities which you do to support your personal / psychospiritual growth? (e.g. counseling, meditation, yoga, etc.)*Do you have any questions about the workshop, or concerns about participating at this time?* BREATHWORK NORTHWEST PARTICIPANT CONTRACT RELEASE, WAIVER, AND INDEMNITY OF LIABILITY AGREEMENT Finally, please read and sign your consent to the following statements about the Breathwork Northwest Holotropic Breathwork® workshop: In consideration of being admitted to the Program and permitted to participate in the activities and Holotropic Breathwork® ("HB") I hereby agree as follows: This Agreement is made and entered into under the laws of the State of Washington and the United States and shall be interpreted, governed and enforced under and pursuant to these laws. Participant agrees that should an action be brought against Breathwork NW or its agents for any reason whether to enforce the terms of this agreement or on some other basis, that all disputes between Participant and Breathwork NW or its agents will be litigated in King County, Washington and Participant waives any rights he/she may have in litigating in any other jurisdiction. Participant has filled out the Medical Information Form and certifies that he/she does not have any medical or physical conditions which would impair or affect his/her ability to engage in any activities or which would cause any risk of harm to Participant, other participants and/or Breathwork NW or its agents or otherwise endanger Participant’s health while attending a Breathwork NW Program. Participant further agrees that it is Participant’s responsibility to maintain the accuracy and contemporaneousness of the Medical Information Form. Breathwork NW will assume that Participant’s Medical Information Form is correct until Participant files an updated or corrected form. The medical information is fully incorporated by reference within this agreement. Participant is aware that certain activities he/she may engage in during the Program are physically, emotionally and mentally stressful. Participant agrees to assume full responsibility for his/her own physical, emotional and mental health and hold harmless Breathwork NW and its agents from any physical, emotional and/or mental damage that may be attributed to Breathwork NW or its agents. Participant further holds harmless Breathwork NW and its agents from any and all loss, liability, injury, damage or cost which may arise out of or in connection with participation in the Program. Participant understands and agrees that he/she is attending the Program at the discretion of Breathwork NW and can be dismissed from the Program at any time without being informed of the reason for dismissal. Participant waives, releases and discharges any and all claims, rights and/or causes of action which he/she now have or which may arise out of or in connection with participation in the Program as well as which may arise out of or in connection with Participant’s attendance and/or participation in the activities associated with the Program. Therefore, under no circumstance will Participant prosecute or present any claim for personal injury, property damage or any other cause of action against Breathwork NW or its agents. This agreement is binding on Participant’s heirs, assignees, dependents, personal representatives and estate. No oral representations, statements or inducements have been made to Participant to cause them to enter into this agreement. At the choosing of Breathwork NW any claim or controversy that arises out of or relates to this agreement, or the breach of it, may be settled by arbitration in accordance with the rules of the American Arbitration Association. Such arbitration shall be binding upon the parties and Judgment upon the award rendered may be entered in any court with jurisdiction. Should Breathwork NW or its agents be successful in bringing an action to enforce the terms hereof or successful in defending itself from a suit brought by Participant, Breathwork NW or its agents shall recover all costs and expenses incurred in such action, inc. reasonable attorneys’ fees. Should any provision of this Agreement be held invalid or illegal, such illegality shall not invalidate the remainder of this Agreement. In that event, this Agreement shall be construed as if it did not contain the invalid or illegal part, and the rights and obligations of the parties shall be construed and enforced accordingly. I have read this agreement and understand it contains release of all claims language for injuries and damages. I voluntarily sign my name evidencing acceptance of the provisions of this agreement. If English is not my native language I have either studied enough English to be able to read and understand this agreement, or I have had this agreement explained to me in my native language. Electronic Signature* I agree to submit this application electronically. By typing my name below I hereby certify that I have answered all questions honestly and completely, and that I am electronically signing my name. Name* First Last Make Your PaymentAfter making your payment be sure to return here and hit the "Submit Registration" button below to complete the registration process. Would you like to pay for an additional person, besides yourself, to attend? No Yes Name of the additional person for this payment Be sure to select 2 people in the payment form below. This person must also complete the registration form, however they can skip the payment section and go directly to the Submit Registration button. Oct 24 Workshop at Shadow Lake Tier 3 Registration - $350 USDTier 2 Registration - $300 USDTier 1 Registration - $250 USDMental Health Student/Veteran Registration - $125 USD 12 Submit Your RegistrationYou're almost there! After completing your payment above, just hit the Submit Registration button below to complete your registration.EmailThis field is for validation purposes and should be left unchanged.
