Signature Required Prior to Scheduled Appointment

ELSEN HYPNOTHERAPY/Path of Light Center, Certified Regression Therapists

WAIVER AND RELEASE AND LIABILITY

In consideration of the risk of injury that exists in traveling to and from/participating in REGRESSION THERAPY and entering and exiting an (office) building/property (hereinafter the “Activity”); and

In consideration of my desire to participate in said activity and being given the right to participate in same;

I HEREBY, for myself, my heirs, executors, administrators, assigns, or personal representatives (hereinafter collectively, “Releasor,” “I” or “me”, which terms shall also include Releasor’s parents or guardian, knowingly and voluntarily enter into this WAIVER AND RELEASE OF LIABILITY and hereby waive any and all rights, claims or causes of action of any kind arising out of my participation in the Activity; and

I HEREBY release and forever discharge Pieter Elsen and Jenna Iantorno Elsen (hereinafter “ELSEN HYPNOTHERAPY/PATH OF LIGHT CENTER”, irrespective of office location used, anywhere, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns (collectively “Releasees”), from any injury that I may suffer as a direct result of my participation in the aforementioned Activity.

I AM VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED ACTIVITY AND I AM PARTICIPATING IN THE ACTIVITY ENTIRELY AT MY OWN RISK. I UNDERSTAND THAT THESE INJURIES OR OUTCOMES MAY ARISE FROM MY OWN OR OTHERS’ NEGLIGENCE, CONDITIONS AT THE ACTIVITY LOCATION(S), NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWING AND UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY.

I FURTHER AGREE to indemnify, defend and hold harmless the Releasees against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney’s fees and any related costs.

I FURTHER ACKNOWLEDGE that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize ELSEN HYPNOTHERAPY/PATH OF LIGHT CENTER to provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personal. I further agree to assume all costs involved and agree to be financially responsible for any costs incurred as a result of such treatment. A am aware that I should carry my own health insurance.

I FURTHER ACKNOWLEDGE and agree not to participate in the Activity unless I am medically and psychologically able, and I agree to abide by the decisions of the ELSEN HYPNOTHERAPY/PATH OF LIGHT CENTER official or agent, regarding my approval to participate in the Activity.

I HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS “WAIVER AND RELEASE” AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. I EXPRESSIVELY AGREE TO RELEASE AND DISCHARGE ELSEN HYPNOTHERAPY/PATH OF LIGHT CENTER AND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS, AGENTS, ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND ASSIGNS, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE AND RIGHTS THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST ELSEN HYPNOTHERAPY/PATH OF LIGHT CENTER FOR PERSONAL INJURY OR PROPERTY DAMAGE.

I agree that this Release shall be governed for all purposes by US Law, irrespective of state and location, without regard to any conflict of law principles. This Release supersedes any and all previous oral or written promises or other agreements.

I, THE UNDERSIGNED PARTICIPANT, AFFIRM THAT I AM OF THE AGE OF 18 YEARS OR OLDER, AND THAT I AM FREELY SIGNING THIS AGREEMENT. I CERTIFY THAT I HAVE READ THIS AGREEMENT, THAT I FULLY UNDERSTAND ITS CONTENTS AND THAT THIS RELEASE CANNOT BE MODIFIED ORALLY. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND THAT I AM SIGNING IT OF MY OWN FREE WILL.

(Initial)

Acknowledgment of Services and Fees: Subject: Self Improvement Program

I, the undersigned, acknowledge that I understand and agree to the following:

I agree to pay Elsen Hypnotherapy/Path of Light Center*, Certified Clinical Hypnotherapists and Certified Regression Therapists, a non-refundable 50% deposit fee of $390 per Regression session at the time of booking, plus $390 on the day of the session, totaling $780. I agree to pay, in full, for your services on the date of the LBL session this $780.

I agree that deposits are non-refundable. I understand that missing a scheduled appointment without prior cancellation, or with cancellation less than 7 days before the scheduled session, will be charged to me at the current full rate, understanding that Elsen Hypnotherapy/Path of Light Center has overhead costs (offices/travel/reservations etc.) that usually cannot be canceled on short notice.

I understand that the program of conditioning offered by you for the fees described above will include one regression session only. I understand and agree that the major purpose of this program is for Vocational or Avocational Self-improvement and those problems of psychogenic or functional origin are treated by psychological or medical referrals only (Business and Professional Code 2908). I also understand that there are no guarantees as to the results or progress to be made, only that you will, to the best of your ability, endeavor to accomplish the objective of the sessions. I claim no refund accordingly or hold Elsen Hypnotherapy/Path of Light Center responsible in any way, including financially, legally, or otherwise. I, therefore, understand that I will be paying $780 for the session, regardless of 'results', understanding that the regression process is equally applied to all clients without variations, and that difference in results, therefore, are the result of my mind, and not the process Elsen Hypnotherapy/Path of Light Center is applying. I also agree to allow Elsen Hypnotherapy/Path of Light Center in its capacity as a therapist to touch my arm, shoulder for the purpose of establishing hypnotic anchors required as deepening techniques for my session.

(Initial)

RELEASE AGREEMENT

Whereas, Elsen Hypnotherapy/Path of Light Center is engaged in REGRESSION SESSIONS and

Whereas, I, the undersigned, am appearing on the audio recording of the regression session, and

Whereas, I understand that my voice and name will be recorded by various mechanical and electrical means of all descriptions (such recordings, any piece thereof, the contents therein and all reproductions thereof, along with the utilization of my name, shall be collectively referred to herein as the "Released Subject Matter"),

Therefore, without claiming any reward or compensation, monetary or otherwise, now or hereafter, I hereby freely and without restraint consent to and give unto the Pieter Elsen and Jenna Iantorno, (collectively referred to herein as "Elsen Hypnotherapy/Path of Light Center") the unrestrained right in perpetuity to own the Released Subject Matter, all of the foregoing to be without limitation of any kind. I hereby stipulate that the Released Subject Matter is the property of the Path of Light Center (the recording will not be utilized without permission from the client).

I hereby waive to the fullest extent that I may lawfully do so, any causes of action in law or equity I may have or may hereafter acquire against the Releasees or any of them for libel, slander, invasion of privacy, copyright or trademark violation, right of publicity, or false light arising out of or in connection with the utilization by the Releasees or another of the Released Subject Matter.

It is my intention not to claim any reward or compensation, monetary or otherwise, now or hereafter, in connection with any and all usages of the Released Subject Matter. I expressly stipulate that the Releasees may utilize the Released Subject Matter or not as they choose in their sole discretion without affecting the validity of this Release. This Release shall be governed by US Federal Law.

I also agree to keep confidential the contents of this session, as well as the regression script used during the session, and agree not to share, utilize, distribute, use for personal gain or otherwise the materials and techniques used during the session, being hereby informed the materials/scripts/techniques are copyrighted and protected by Elsen Hypnotherapy/Path of Light Center, (I will receive a copy of the recording of the session, starting from the point of Age 12 of the age regression from Elsen Hypnotherapy/Path of Light Center). I will NOT record the session secretly during the meeting with for example a recorder or on my cell phone.

I hereby certify that I am over the age of eighteen and that I have read, understood, and agreed to the foregoing.

(initial)

COVID-19 Liability Release Waiver

Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), Elsen Hypnotherapy is taking extra precautions with the care of every client to include health history review and enhanced sanitation/disinfection procedures in accordance CDC Professional and Occupational Regulation guidance.

Symptoms of COVID-19 include:

• Fever
• Fatigue
• Dry Cough
• Difficulty Breathing

I agree to the following:

I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above WITHIN THE LAST 14 DAYS. I affirm that I, as well as all household members, have not been diagnosed with COVID-19 WITHIN THE PAST 30 DAYS. I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 WITHIN THE PAST 30 DAYS. I affirm that I, as well as all household members, have not traveled outside of the country, or to any city considered to be a "hot spot" for COVID-19 infections WITHIN THE PAST 30 DAYS. I understand that Elsen Hypnotherapy cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client. All surfaces will be wiped thoroughly with hospital grade disinfectant before and after each client according to the manufacturer's directions

By signing below, I agree to each statement above and release Pieter Elsen from any and all liability for the unintentional exposure or harm due to COVID-19.

(Signature)

(initial)

*Pieter Elsen / Jenna Iantorno-Elsen / Path of Light Center / Elsen Hypnotherapy

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