Consent Form for Participation in Mindfulness Courses
This consent form is mandatory for participation in courses and workshops at the Center for Child and Family Well-Being.
I hereby give my consent to participate in the following live online course via Zoom, Be REAL Facilitator Training, with the facilitator(s) Sara McDermott and Megan Kennedy. I understand that my participation in any part of the course is voluntary. I understand that I can stop participating in any activity at any time if I so choose, at any point throughout the course.
Risks, Stress, Discomfort
I understand that I may feel mentally and/or physically uncomfortable during parts of the course. I understand some movement exercises, which are part of the course, may lead to injury. It is my responsibility to do all exercises in an aware and gentle manner so as to minimize chance of injury. I understand there may be other risks associated with the course not known to me or not reasonably foreseeable at this time. I understand that I am solely responsible for the care for all aspects of myself.
I understand the course is offered as an educational experience, and is in no way the practice of medicine or a substitute for medical attention, examination, diagnosis or treatment. I also understand that this course is not a mental health treatment or a substitute for diagnosis or treatment for a mental health or substance use disorders such as depression, anxiety, or addiction. I understand that nothing that goes on in the course is designed to treat any specific condition.
I acknowledge that there are certain risks inherent in participating in an online program, including but not limited to data mining, phishing, viruses, malware, data breach of online information, cyberbullying, exploitation, victimization, cyber stalking, cyber predators, and image replication. I acknowledge that all risks cannot be prevented and I assume those risks beyond the reasonable control of the University staff. I represent that I am able to use the technology and/or supplies described above.
Confidentiality
I understand that all communication during this course is confidential, and I agree not to discuss with or approach members of the course outside of the course about anything personal shared in the course. I further will not discuss the communication of others in the course with anyone not in the course.
Conclusion
I confirm that I understand the risks and cautions associated with taking this course. I understand that the facilitator(s), at their sole discretion and either in the interest of the group or of myself, may withdraw me from the course.
I acknowledge that I have read this entire document, that I understand its terms and provisions, that it is a binding agreement, that by signing it I am giving up substantial legal rights I might otherwise have, and that I am signing it knowingly and voluntarily. I agree for myself, my heirs, administrators, personal representatives, and assigns, to hold harmless the University of Washington Center for Child and Family Well-Being, its faculty and staff, the course facilitator(s), and any and all of their associates, employees, volunteers, agents, successors, or assigns (the “Released Parties”), from any and all liabilities, losses, costs, claims, demands or causes of action, past, present and future, known or unknown, relating to any actions in the course or any harm, physical or mental, that results from my participation in the course, and agree to indemnify the Released Parties for all judgments, costs, attorney fees and other expenses incurred as a result of a breach of this agreement.
DISCLAIMER: By drawing/typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
