Registration Form (please fill out the form and send it back to me either by regular mail or by e-mail scan; for a private session please contact me directly by phone or by e-mail) Agreement between Name: ..................................................................................................................................................... Address: ................................................................................................................................................ City/Code/Country: ........................................................................................................................... Phone: .......................................................... e-mail: ............................................................... (hereinafter referred to as the "Participant") and Daniel M. Finke Heidemühler Weg 21 15366 Hoppegarten Phone: +49-30-55125823 e-mail: [email protected] (hereinafter referred to as the "Workshop Facilitator"). Hereby, the participant registers for the following workshop: “Finding your Clarity“ - Weekend workshop with Holotropic Breathwork Workshop dates: ....................................................... Workshop fee: € 190,00 Terms and Conditions 1. Registration and Cancellation This registration is binding and leads to the obligation to pay the workshop fees. If the workshop already is fully booked, the Participant’s registration will be put onto a wait list. The Workshop Facilitator will confirm registration or wait list entry either by mail or e-mail. The Participant can cancel the registration by phone, mail, e-mail, or in person. Already paid fees will be reimbursed only if another person will participate instead – either a person recommended by the Participant, or a person from the waitlist. If the cancelled registration cannot be filled with another person, the following cancellation fees apply: • • • Until 31 days before workshop start: €30,- administration fee, 30 to 15 days before workshop start: 50% of the workshop fees, Less than 14 days before workshop start: 100% of the workshop fees. Daniel M. Finke * Heidemühler Weg 21 * 15366 Hoppegarten * Phone: +49-30-55125823 e-mail: [email protected] * Local tax office: Finanzamt Strausberg – Steuernummer 064/219/01773. Cancellation fees also apply in case of short-term cancellation due to health reasons and in in case of the Participant leaving the workshop early. 2. Payment Fees are due after confirmed registration, latest at workshop start. Fees are to be paid cash or by bank transfer (with reference to the workshop dates and Participant’s name) to the following account: Daniel M. Finke Bank: Berliner Sparkasse Account No.: 6015593286 Bank No.: 10050000 IBAN: DE56 1005 0000 6015 5932 86 BIC-/SWIFT-Code: BE LA DE BE 3. Cancellation by the Workshop Facilitator All workshops require a minimum number of participants. If this number will not be reached the Workshop Facilitator can cancel the workshop at his sole discretion. In such case, already paid fees will be fully reimbursed. In case the Workshop Facilitator is not able to continue a workshop that already has been started, fees will be reimbursed on a pro-rata basis. Further claims cannot be made. 4. Confidentiality The Workshop Facilitator is subject to legal requirements concerning confidential medical communications. In case the Workshop Facilitator has to provide medical information to public authorities or Participant’s family members, a formal confidentiality release issued by the Participant is required. The Workshop Facilitator may be legally required to break confidentiality in order to protect the Participant or other persons. In case of Participant’s suicidal tendencies the Workshop Facilitator is allowed to inform Participant’s family members. Also, if the Workshop Facilitator is informed about sexual abuse of minors, he is released from confidentiality in front of police and relevant public authorities. 5. Other For methodical reasons all participants are required to continuously attend the workshop. The Participant attends the workshop voluntarily at his/her own responsibility. It is the Participant’s responsibility to make sure that relevant insurance cover exist (personal health insurance and optional accident insurance). If not agreed otherwise, accommodation is not included in this agreement, even in case of workshops lasting several days. Birthdate: ....................................... Date: ....................................... Signature: .................................................................................................................... Daniel M. Finke * Heidemühler Weg 21 * 15366 Hoppegarten * Phone: +49-30-55125823 e-mail: [email protected] * Local tax office: Finanzamt Strausberg – Steuernummer 064/219/01773. Holotropic Breathwork™ – Medical Information Form Holotropic Breathwork is a depth-psychology based method of self-experience and healing. Holotropic Breathwork can involve dramatic experiences accompanied by strong emotional and physical release. It is not appropriate for pregnant women, or for persons with cardiovascular problems, severe hypertension, severe mental illness, recent surgery or fractures, acute infectious illness or epilepsy. If you have any doubt about whether you should participate, consult your physician or therapist, as well as the workshop facilitator before attending. The answers to the following questions are to assist your facilitator and will be kept strictly confidential. Name: .........................................................................................Date of birth: ............................................. 1. Do you have a past history of, or currently suffer from any of the following: a. Cardiovascular disease, including heart attacks b. High blood pressure c. Severe mental illness d. Recent surgery e. Past or recent physical injuries, including fractures or dislocations f. Present or current infectious or communicable diseases g. Glaucoma h. Retinal detachment i. Epilepsy j. Osteoporosis k. Asthma (if yes, please bring your inhaler to the workshop 2. 3. 4. 5. 6. 7. 8. YES / NO ....... /....... ....... /....... ....... /....... ....... /....... ....... /....... ....... /....... ....... /....... ....... /....... ....... /....... ....... /....... ....... /....... Are you currently pregnant? ....... /....... Have you ever been hospitalized for medical reasons? ....... Have you ever been psychiatrically hospitalized? ....... Are you currently in therapy or involved in any type of support group? ....... Are you currently taking any type of medication? ....... Have there been any difficulties during your birth? (e.g. caesarean section, anaesthesia) ....... Is there anything else about your physical or emotional status we should be aware of? ....... /....... /....... /....... /....... /....... /....... If you answer "yes" to any of these questions, please explain or elaborate on the back of this form. I hereby confirm that I have read and understood the above information, and have answered all questions completely and honestly, and have not withheld any information. Signature: ............................................................................Date: .............................................. Daniel M. Finke * Heidemühler Weg 21 * 15366 Hoppegarten * Phone: +49-30-55125823 e-mail: [email protected] * Local tax office: Finanzamt Strausberg – Steuernummer 064/219/01773.
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