I, (name typed below), acknowledge that I have voluntarily applied to participate in the following service.

AM AWARE THAT WAFA' AKL IS NOT A DOCTOR AND THAT SHE IS A CONSULTANT . I AM VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES WITH KNOWLEDGE OF I HAVE TO CONSULT MY DOCTOR PRIOR TO STARTING THIS SERVICE. I AM ALSO AWARE THAT THE MEDICATION DOZE PRESCRIBED BY MY TREATING PHYSICIAN MIGHT NEED TO BE ADJUSTED OR ELIMINATED DUE TO FOLLOWING THE SERVICE. I AGREE TO ASSUME ANY AND ALL OF THE BODILY CHANGES. I VOLUNTARILY CHOSE TO BE TREATED HOLISTICALLY WITH ALL THE CONSCIOUSNESS RESULTING FROM MY SERVICE.

As consideration for being permitted by the service recommendation , I forever release Wafa' Akl from any and all actions, claims, and legal representatives now have, or may have in the future, for injury, related to (i) my participation in these recommendation, (ii) the negligence or other acts, whether directly connected to this service or not, and however caused, by any Release, or (iii) the condition of the premises where these activities occur, whether or not I am then participating in the activities (N/A).

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN MYSELF AND THE  COUNSELOR WAFA' AKL, AND SIGN IT BY TYPING MY NAME BELOW OF MY OWN FREE WILL.

If Signed by Parent or Guardian: I verify that the dangers of the activities and the significance of this Release and Waiver were explained to the Participant and that the Participant understood

them.

Guardian Name (if under 18)

IF YOU ARE UNDER 18 YEARS OF AGE, YOU AND YOUR PARENT OR GUARDIAN MUST SIGN AND INITIAL THIS FORM WHERE INDICATED