Nervous System Regulation & Meditation Class

Breathwork Waiver & Release Form - Please reply to the email with your answers

Welcome to Breathwork coaching.

Breathwork is a powerful practice that may involve physical, emotional, and psychological

responses. While it can be deeply healing, it is not a substitute for medical or psychological

treatment.

This document outlines your acknowledgment of potential risks, your health declaration, and your agreement to release Frequency Lifestyles Pty Ltd from liability related to your participation in Breathwork sessions and coaching.

Participation in Breathwork is strictly limited to individuals aged 18 years and over. No persons under the age of 18 will be permitted to attend or participate in any Breathwork classes, workshops, sessions or events (Breathwork Event on 8th June). The Company reserves the right to verify age and refuse entry if this condition is not met.

PERSONAL DETAILS

Full Name (required): ____________________________   Date of Birth (required):____/_____/_______

Home Phone: ________________________________        Mobile (required): ________________

☐ I consent to photographs/videos being used for promotional purposes
☐ I do not consent

EMERGENCY CONTACT DETAILS

Full Name (required): __________________________      Mobile (required): ________________________

PERSONAL EXPERIENCE

Have you had any previous experience with breathwork? If so, please describe.

__________________________________________________________________________________________________________________________________________________________________________________

HEALTH DECLARATION

Do you have any physical health problems or existing medical conditions that might interfere with your ability to participate in breathwork? (Please highlight your answers)

Please indicate in the options below, where applicable to you:

ð      Pregnancy

ð      Respiratory conditions (for example, asthma, COPD, or other lung diseases)

ð      History of Aneurysms

ð      Epilepsy or seizure disorders

ð      Cardiovascular diseases, including heart conditions, high blood pressure or prior heart attacks

ð      HIV +/ AIDS

ð      Any contagious or viral conditions – Please specify

ð      Allergies

ð      High blood pressure

ð      Eating disorder

ð      Mental health disorders (for example, schizophrenia or psychosis)

ð      Glaucoma or Detached Retina

ð      Recent Surgeries or serious physical injuries

ð      None – I have no pre-existing conditions to declare

ð      Any other illnesses or health conditions that require special care please specify below

____________________________________________________________________________________________________________________________________________________________________________________________________

If any of the above apply to you, please consult a medical professional before engaging in

breathwork.

PLEASE READ CAREFULLY BEFORE SIGNING

By signing this form, you acknowledge the following:

1. RISKS AND RESPONSIBILITIES

Your participation in breathwork sessions is entirely voluntary, and you accept full responsibility for your health, safety, and wellbeing throughout the practice.

You understand that breathwork can elicit strong physical sensations and emotional or psychological responses. While these experiences can be beneficial, they may not be suitable for everyone. By participating, you acknowledge and voluntarily assume all known and unknown risks associated with this practice.

If at any time you experience discomfort, pain, dizziness, anxiety, or distress, you agree to stop, modify, or rest as needed and to seek assistance from the instructor or facilitator.

You agree to:

• Follow all instructions and safety guidance provided by the facilitators or instructors.

• Accept that failure to follow these directions is at your own risk.

• Take full responsibility for any injury, illness, or other effects arising from your participation.

• Ensure the safekeeping of your own personal belongings, acknowledging that the organisers are not responsible for any lost, stolen, or damaged items.

2. PERSONAL RESPONSIBILITY AND MEDICAL DISCLAIMER

Breathwork is a wellness practice. It is not a substitute for medical care or mental health treatment.

You are responsible for consulting a qualified healthcare professional regarding any pre-existing or emerging health conditions before, during, or after your participation.

You confirm that you have accurately disclosed all relevant medical conditions, injuries, or health concerns that may affect your ability to safely participate. You also agree to update your facilitator should your health status change at any time.

By signing this form, you acknowledge that you are personally responsible for your wellbeing and participation, based on your own informed decision.

3. LIABILITY WAIVER AND RELEASE

By signing this form, you acknowledge and agree that participation in breathwork sessions is undertaken at your own risk.

You irrevocably release, waive, and discharge the Company, along with its directors, authorised facilitators, instructors, employees, contractors, and representatives (collectively, the “Released Parties”), from all claims, damages, liabilities, or actions arising out of or connected with your participation in breathwork sessions.

You further assume full and sole responsibility for all risks — physical, emotional, mental, or otherwise — and agree that the Released Parties will not be held liable for any loss, injury, or damage, including those resulting from negligence.

This release applies to all forms of participation, including guided sessions, workshops, one-on-one coaching, and use of any facilities or equipment.

4. CONFIDENTIALITY AND CONSENT

Your personal information (including sensitive health details provided above) will be handled in accordance with the Company’s Privacy Policy, available at https://www.frequencylifestyles.com.au/copy-of-copyright-notice or on request. This includes how we collect, store, use, disclose, and protect your information, and your rights to access or correct it.

We may take photographs or videos during the retreat for promotional purposes.

If you do not wish to be photographed, please notify us in writing prior to the event.

By signing below, you confirm that you have read, understood and agree to the terms and conditions outlined in this waiver.

I, ___________________________________________, am participating in breathwork with Frequency Lifestyles Pty Ltd. I accept responsibility for informing Frequency Lifestyles Pty Ltd authorised facilitators, instructors, employees, and/or representatives about any medical conditions, injuries, pregnancy, or changes to my health that may affect my practice, prior to a workshop, event, session or class commencing. I understand it is my personal responsibility to consult with my doctor or health practitioner regarding my participation. I have no medical or mental condition, which would prevent me from taking part in Breathwork. If my health condition should change, I agree to fill out a new Waiver & Release form and advise Frequency Lifestyles Pty Ltd of the new changes. I understand the instructions are intended as guidance and I assume responsibility to practice within my personal limits and to decide whether or not to follow the suggestions provided by the instructor. I have read the above release and waiver of liability and understand its contents. I agree to the terms and conditions stated above.

Date: _____/______/_________                Signature or Initials: ___________________________

Welcome to my monthly Breathwork Nervous System Regulation & Meditation class

What to Know Before We Begin

My calming 1-hour class designed to help you regulate your nervous system, reduce stress, and reconnect with your breath. Through guided breathwork, gentle awareness practices, and meditation, you’ll learn simple yet powerful tools to support your body in shifting out of overwhelm and into a more balanced, grounded state. Perfect for anyone feeling stressed, anxious, or mentally busy, this class offers a supportive space to slow down, reset, and leave feeling clearer, calmer, and more in control.

To help you get the most out of each session, please wear comfortable, loose-fitting clothing that allows you to breathe and move freely. Layers are ideal, as your body temperature can fluctuate during breathwork. You may also like to bring a water bottle, a journal, and anything that helps you feel comfortable (blankets, cushions and mats provided).

For your comfort and safety, please avoid eating heavy meals at least 2 hours before the session. A light snack earlier in the day is perfectly fine. Come well hydrated, avoid excessive caffeine beforehand as it can stimulate the nervous system and impact your experience.

FlourMill Space Unit 106, 3 Gladstone Street, Newtown, NSW, 2042

Event Dates: Monday 13th June

Start Time: 6:30pm

Please aim to arrive 5–10 minutes early so you can settle in and ground yourself before we begin. Sessions will start on time to help maintain a safe and supportive container for the group. If you are running late, please call me on 0473 117 174 and be mindful of the time and experience of the other participants.

If you feel unwell on the day or experience any changes to your health, please reach out prior to attending.

We will send you a reminder email 2 days prior to the class.

I’m honoured you’ve chosen to invest in your wellbeing. This is your time to slow down, breathe deeply, and reset.

Love and Light,

Anna

Frequency Lifestyles

WHERE WELLNESS IS INTENTIONAL