Waiver for Events | KortneeWhitehawk

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ortnee Whitehawk, MS, Ed

Confluence Healing Arts

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Event Participation
Disclosure Statement, Informed Consent, Waiver of Liability, Medical Info, Photo-Release

First Name

Last Name

Email

Are you taking any anti-depressant, anti-anxiety, or anti-psychotic drugs that contain SSRI? *

Yes

No

Do you have any heart problems or heart conditions? *

Yes

No

Are you pregnant, breastfeeding, or is any possibility you are pregnant? *

Yes

No

Are you taking any other medications? *

Yes

No

If you are attending an event that includes the serving of cacao, please read and complete the form below:

During Cacao Ceremony you will be guided on a shamanic journey with a combination of meditation, reiki, nature healing, energy medicine, somatic embodiment, and sound healing processes. Please answer the following questions:

Are you allergic to cacao or chocolate?

Yes

No

Are you highly sensitive to caffeine?

Yes

No

I agree not to consume the cacao beverage if I am allergic to any cacao or chocolate products.

I understand that if I am taking any medication for depression, anxiety or psychosis, or if I have any heart conditions, or if I am pregnant, I may experience an adverse reaction to cacao and therefore I should limit my consumption of cacao.

I acknowledge that cacao has not been evaluated by the FDA and is not intended to diagnose, treat, cure or prevent any disease.

I recognize that I am free to decline to act upon any recommendations as I see fit and that I do not have to participate in any part of the ceremony. I acknowledge my responsibility in communicating any physical and psychological concerns that might conflict with participation in any part of the Cacao Ceremony.

I am aware that various ingredients consumed in Cacao Ceremony may include: Ceremonial grade cacao, cinnamon, oat milk, coconut milk, honey, agave syrup or other natural sweetener, cayenne pepper, and other natural spices.

I agree to assume all risk of personal injury or loss, bodily injury, including death, damage to or loss of, or destruction of any personal property resulting from or arising out of my participation. I also release, waive, indemnify, hold harmless, and discharge Law of Allowing to Confluence Healing Arts/Kortnee Whitehawk McDowell releasing from all claims, damages, and injuries arising out of my participation in the Cacao Ceremony, including my consumption of the cacao beverage.

For all events, please check each box below to confirm the following:

I hereby certify that I am over 18 years of age and that I have read, understood, and accepted all the statements in this document.

I hereby certify and consent to photo and video release for all purposes related to Confluence Healing Arts to include all social media outlets and website.

Select a date

Yes! Send me all the good vibes and good energy. No spam, just soul! My info is protected and I can opt out anytime.

Thanks for submitting your waiver.

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