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September 21st-23rd, 2018 in Hot Springs, NC


Sacred Circle Retreat
Waiver and Release Agreement
Welcome, sister. Thank you for entering in to this agreement to ensure a safe and deep journey for us all...
Name *
Terms and Conditions *
By signing below I certify, agree to, and affirm the following: I understand that Energy Healing/Energy Medicine/Energy Alchemy/Energy Work are complimentary healing modalities that in no way substitute for medical interventions, body therapy, or psychotherapy. I also understand that Jessica Ricchetti may make suggestions for self-care as well as appropriate referrals. I understand that Jessica Ricchetti does not diagnose, treat, or cure and I will not misconstrue any information to be identified as such. I acknowledge that an open communication is promoted between myself and Jessica Ricchetti to enhance a mutual understanding and acceptance of the energy work provided during the treatment setting. I further understand that there are numerous benefits possible through Energy Healing/Energy Medicine/Energy Alchemy/Energy Work, such as spiritual expansion, kundalini awakening, diminished pain sensation, healing, transformation, increased relaxation, relief from anxiety, and enhanced sense of well-being. These effects may vary depending on each individual’s response patterns. Although there are no known harmful effects from this type of healing, I hold Jessica Ricchetti harmless from any possible effects that may cause temporary physical or emotional discomfort and agree to take full responsibility for my self-care and personal development. I know that this journey will involve deep psychic explorations, breathwork, body movement, and energy movement that may push my edges at moments. I will remain self-responsible to know my limits and not exceed them. If a practice is suggested that may push beyond my limits, I will remain self-responsible to stop or modify the practice. I am in control of my own body and I can always “stop” at any time. I certify that I do not have any injuries, illnesses, diseases, and/or health concerns including and not limited to physical, mental, emotional, and/or spiritual health that would prevent me from participating in this retreat. If I have any question about this, I know that it is my responsibility to consult with a licensed medical practitioner prior to the retreat. I will seek professional help if needed. I will advise Jessica Ricchetti of any mental or physical health conditions, concerns, and dietary requirements upon signing of this agreement. If I have health conditions and dietary requirements that may be affected by the activities offered on our retreats, I know that Jessica Ricchetti reserves the right to advise me to desist and in the interests of my wellbeing, or others, she may decline my stay at the retreat. Jessica Ricchetti is not liable for any medical or psychiatric conditions, which may develop during or subsequent to the retreat. I also acknowledge that it is not the responsibility of Jessica Ricchetti to advise me in regards to my health or well-being, as she is not a medical nor psychiatric practitioner. I understand and agree that I am fully responsible for my own self-care & well-being. I affirm that I am of sound mental health to makes such an agreement. I know that I can choose to withdraw from any experience at any time without judgement. I know that this is a sacred space of deep energetic transmission. I know there is a possibility for triggering intense emotions, memories, and experiences. If I am feeling triggered, I know that it is safe to consciously bring it to Jessica Ricchetti and to the circle space, and I will remain in responsibility for my own being. If I am or become pregnant, I will inform Jessica Ricchetti prior to the retreat, and/or upon signing this agreement, as well as at any time pregnancy status changes. Whilst all measures are taken to ensure a high standard of health and safety, I know that we are situated in the mountains where the land is uneven. I hold harmless both Jessica Ricchetti, the ChakraSamvara center, and all associated persons, for any injuries caused by uneven terrain. Complaints: If I have a problem during the retreat, I will inform Jessica Ricchetti immediately and she will endeavor to put things right. I further note that she is not responsible for the individual behavior of any group member or other guest sharing my accommodation. Cancellation by me: Bookings are for the stated period of the retreat. There are no refunds for an unused portion of the retreat. Amendments by Jessica Ricchetti: Occasionally, changes may have to be made (e.g., facilitator, schedule structure, or other arrangements), and the right is reserved for the facilitators to do so at any time. No Liability for possessions: The retreat house may be left unlocked at any time, and it is my own responsibility to ensure that my possessions are kept safe. I will consider leaving valuables at home or locked in my vehicle if this is a concern. Privacy Policy: Jessica Ricchetti does not share personal details with any third parties. Any personal information that I provide will be used only for the service I requested. This information is used only for administration of the site system and in the compilation of statistics used to assess the use of the site. This privacy policy does not cover the links within this site linking to other sites. Photography: I agree to not take any photographs of Jessica Ricchetti, any participants, or any ceremony/circle/activity without express prior consent. I agree not post or use any photographs taken of Jessica Ricchetti, or taken over the duration of the retreat without express prior consent of Jessica Ricchetti. I consent to photographs being taken by Jessica Ricchetti and/or her team at any point during/before/after the retreat. I hereby grant the Jessica Ricchetti permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration. Travel Arrangements: Jessica Ricchetti shall not be held liable for any consequences arising from delays or cancellations in any travel, as well as unexpected cancellation, sickness, losses and all usual risks. Transfers to/from the retreat are at my own cost. ChakraSamvara Retreat Center Terms and Conditions: (I acknowledge that my role is "guest" in the following terms) Damages: All damages will be the responsibility of Guest and include but are not limited to liability for damage due to the following: (a) intentional, willful, reckless, or malicious acts of Guest or others on the premises during the tenancy; (b) theft from the premises of either the Owner's property or property belonging to Guest; (c) gross negligence of Guest or intentional misuse of furnishings, appliances, equipment, or other amenities provided with the home; (d) damage caused while under the influence of alcohol or drugs; (e) damages to real property resulting from operation of any motorized vehicle by Guest. This liability shall extend to all members of Guest's party. Indemnification and Hold Harmless: Guest agrees to indemnify and hold harmless Mai Pham Nguyen, and ChakraSamvara Center, Inc. management agency, from and against any liability for personal injury or property damaged sustained by any person (including guests’ guests) as a result of any cause, unless caused by the negligent or willful act of Owner or agency, to comply with the VRA. Owner has provided a copy of the Vacation Rental Agreement.
Date *
By typing my full name below, I affirm that I am signing a digital signature in place of a physical signature. I know that I have the option to sign a physical copy of this waiver in person if I choose, in lieu of this form.
Is there any possibility that you are pregnant? *