New Student Registration & TermsStudent Full Name Your Email Address INFORMED CONSENT FORM – PART 1 Informed Consent Agreements: I am participating of my own free choice and not as a result of coercion, pressure, or to satisfy anyone other than myself. I am aware and understand that this experience involves a potential risk of physical and/or emotional stress. I agree that Global Breathing Awareness is responsible only for the orderly presentation of the experience and that I am responsible for my own participation and my own well-being. I hereby voluntarily consent to participate in this program. I understand this program is educational. It is not a substitute for psychotherapy. I understand that I am responsible for my own health care needs before, during and after the program. I understand that, in addition to the benefit, there is always the risk of emotional and/or medical contingencies in such a group experience. I take responsibility for consulting with a medical doctor and/or my therapist concerning any known or potential physical or mental condition that I have or may have, for the purpose of getting medical permission to participate in the program if needed. I assume the risk, by this consent, of any illness during the program, and hereby release the Global Breathing Awareness/RBT Training staff from liability there from. I agree to respect the timings of the training. I agree to be on time for any appointments and in submitting my homework. If I have an urgent matter to contend to which may cause me to be late, I must inform GBA/RBT staff. I understand that GBA reserves the right to absolute uninterrupted privacy once live online sessions or processes start, and therefore realize that if I am not on time, I may not be permitted to enter or participate for that part of the program. I understand that during the online class/processes, that mobile phones are not to be used or checked. I can check my mobile during breaks. I can inform GBA staff if mobile use is essential. I understand that any form of illegal drug use, as well as the use of new age “medicines” (mushrooms etc.), will not be tolerated during the program. If I show up for sessions or processes under the influence of drugs/alcohol or “medicines”, GBA reserves the right to refuse my entry, or even disqualify me from the course if necessary. I agree to dress modestly and comfortably during the duration of the processes or sessions, or any time I am visible to other students. I agree to participate fully in every given exercise or activity. “Just observing” the exercise is not accepted. I agree not to train other people to become Rebirth Breath Therapists (RBT) or Breathworkers until I have completed all requirements for – and received a Level 5 certificate from - Global Breathing Awareness/RBT. To receive certification as a Rebirth Breath Therapy Practitioner, I agree to: Attend and successfully complete the whole corpus of the educational material of Level 1 and 2. Be present all days of the program in order to complete all requirements needed for certification by Global Breathing Awareness/RBT. iii. Complete the practical requirements of putting 3 people through 10 supervised consecutive documented sessions each (30 full sessions), and submit all documents and forms needed. I agree not to use Rebirth Breath Therapy in a professional capacity, whether that is giving sessions, seminars or trainings, until I have completed all requirements for – and received a practitioner’s certificate from - Global Breathing Awareness. INFORMED CONSENT FORM – PART 2 PERSONAL INFORMATIONYour Address Postcode City Your Country Andorra, Principality ofUnited Arab EmiratesAfghanistan, Islamic Republic ofAntigua and BarbudaAnguillaAlbania, Republic ofArmenia, Republic ofNetherlands AntillesAngola, Republic ofAntarctica (the territory South of 60 deg S)Argentina, Argentine RepublicAmerican SamoaAustria, Republic ofAustralia, Commonwealth ofArubaÅland IslandsAzerbaijan, Republic ofBosnia and HerzegovinaBarbadosBangladesh, People Republic ofBelgium, Kingdom ofBurkina FasoBulgaria, Republic ofBahrain, Kingdom ofBurundi, Republic ofBenin, Republic ofSaint BarthelemyBermudaBrunei DarussalamBolivia, Republic ofBonaire, Sint Eustatius and SabaBrazil, Federative Republic ofBahamas, Commonwealth of theBhutan, Kingdom ofBouvet Island (Bouvetoya)Botswana, Republic ofBelarus, Republic ofBelizeCanadaCocos (Keeling) IslandsCongo, Democratic Republic of theCentral African RepublicCongo, Republic of theSwitzerland, Swiss ConfederationIvory Coast, Republic ofCook IslandsChile, Republic ofCameroon, Republic ofChina, People Republic ofColombia, Republic ofCosta Rica, Republic ofCuba, Republic ofCape Verde, Republic ofCuraçaoChristmas IslandCyprus, Republic ofCzech RepublicGermany, Federal Republic ofDjibouti, Republic ofDenmark, Kingdom ofDominica, Commonwealth ofDominican RepublicAlgeriaEcuador, Republic ofEstonia, Republic ofEgypt, Arab Republic ofWestern SaharaEritrea, State ofSpain, Kingdom ofEthiopia, Federal Democratic Republic ofFinland, Republic ofFiji, Republic of the Fiji IslandsFalkland Islands (Malvinas)Micronesia, Federated States ofFaroe IslandsFrance, French RepublicGabon, Gabonese RepublicUnited Kingdom of Great Britain & Northern IrelandGrenadaGeorgiaFrench GuianaGuernsey, Bailiwick ofGhana, Republic ofGibraltarGreenlandGambia, Republic of theGuinea, Republic ofGuadeloupeEquatorial Guinea, Republic ofGreece, Hellenic RepublicSouth Georgia and the South Sandwich IslandsGuatemala, Republic ofGuamGuinea-Bissau, Republic ofGuyana, Co-operative Republic ofHong Kong, Special Administrative Region of ChinaHeard Island and McDonald IslandsHonduras, Republic ofCroatia, Republic ofHaiti, Republic ofHungary, Republic ofIndonesia, Republic ofIrelandIsrael, State ofIsle of ManIndia, Republic ofBritish Indian Ocean Territory (Chagos Archipelago)Iraq, Republic ofIran, Islamic Republic ofIceland, Republic ofItaly, Italian RepublicJersey, Bailiwick ofJamaicaJordan, Hashemite Kingdom ofJapanKenya, Republic ofKyrgyz RepublicCambodia, Kingdom ofKiribati, Republic ofComoros, Union of theSaint Kitts and Nevis, Federation ofKorea, Democratic Peoples Republic ofKorea, Republic ofKuwait, State ofCayman IslandsKazakhstan, Republic ofLao, People Democratic RepublicLebanon, Lebanese RepublicSaint LuciaLiechtenstein, Principality ofSri Lanka, Democratic Socialist Republic ofLiberia, Republic ofLesotho, Kingdom ofLithuania, Republic ofLuxembourg, Grand Duchy ofLatvia, Republic ofLibyan Arab JamahiriyaMorocco, Kingdom ofMonaco, Principality ofMoldova, Republic ofMontenegro, Republic ofSaint MartinMadagascar, Republic ofMarshall Islands, Republic of theMacedonia, The Former Yugoslav Republic ofMali, Republic ofMyanmar, Union ofMongoliaMacao, Special Administrative Region of ChinaNorthern Mariana Islands, Commonwealth of theMartiniqueMauritania, Islamic Republic ofMontserratMalta, Republic ofMauritius, Republic ofMaldives, Republic ofMalawi, Republic ofMexico, United Mexican StatesMalaysiaMozambique, Republic ofNamibia, Republic ofNew CaledoniaNiger, Republic ofNorfolk IslandNigeria, Federal Republic ofNicaragua, Republic ofNetherlands, Kingdom of theNorway, Kingdom ofNepal, State ofNauru, Republic ofNiueNew ZealandOman, Sultanate ofPanama, Republic ofPeru, Republic ofFrench PolynesiaPapua New Guinea, Independent State ofPhilippines, Republic of thePakistan, Islamic Republic ofPoland, Republic ofSaint Pierre and MiquelonPitcairn IslandsPuerto Rico, Commonwealth ofPalestinian Territory, OccupiedPortugal, Portuguese RepublicPalau, Republic ofParaguay, Republic ofQatar, State ofReunionRomaniaSerbia, Republic ofRussian FederationRwanda, Republic ofSaudi Arabia, Kingdom ofSolomon IslandsSeychelles, Republic ofSudan, Republic ofSweden, Kingdom ofSingapore, Republic ofSaint HelenaSlovenia, Republic ofSvalbard & Jan Mayen IslandsSlovakia (Slovak Republic)Sierra Leone, Republic ofSan Marino, Republic ofSenegal, Republic ofSomalia, Somali RepublicSuriname, Republic ofSouth SudanSao Tome and Principe, Democratic Republic ofEl Salvador, Republic ofSint Maarten (Netherlands)Syrian Arab RepublicSwaziland, Kingdom ofTurks and Caicos IslandsChad, Republic ofFrench Southern TerritoriesTogo, Togolese RepublicThailand, Kingdom ofTajikistan, Republic ofTokelauTimor-Leste, Democratic Republic ofTurkmenistanTunisia, Tunisian RepublicTonga, Kingdom ofTurkey, Republic ofTrinidad and Tobago, Republic ofTuvaluTaiwanTanzania, United Republic ofUkraineUganda, Republic ofUnited States Minor Outlying IslandsUnited States of AmericaUruguay, Eastern Republic ofUzbekistan, Republic ofHoly See (Vatican City State)Saint Vincent and the GrenadinesVenezuela, Bolivarian Republic ofBritish Virgin IslandsUnited States Virgin IslandsVietnam, Socialist Republic ofVanuatu, Republic ofWallis and FutunaSamoa, Independent State ofUnited Nations Neutral ZoneIraq-Saudi Arabia Neutral ZoneSpratly IslandsDisputed TerritoryYemenMayotteSouth Africa, Republic ofZambia, Republic ofZimbabwe, Republic ofMobile Phone Home PhoneWork PhoneEmergency Contact Emergency Contact's Telephone Number(s) Site/blogInstagramFacebookMarital Status Age Your Occupation Blood Type (in case of a medical emergency) HEALTH INFORMATION List any prescription medications you are now taking, and what they are for: Do you have any physical conditions /limitations we need to be aware of? NoYesIf Yes, please describe themHave you ever been treated for (confirm with tick)DepressionAlcoholismDrug or Chemical DependencyEating DisorderOther emotional problemsPsychiatric DisorderHeart or lung issuesAre you currently in any type of counseling? Are you presently having thoughts about suicide? Would you like to mention anything else which may be relevant?List any personal growth seminars previously attended. CANCELLATION POLICY I can cancel my payment and ask for a full refund within 14 calendar days after payment received. I don’t need a reason to justify my decision to cancel my payment.[1] No refund will be returned to me after I have started to download documents or if I have started the course or had any educational interaction with any person of the GBA/RBT staff.[2] No program booking will be final and confirmed until the full amount or the agreed payment is paid either by credit card, cash or bank transfer. No program booking will be final and confirmed until this registration form has been filled in, signed, scanned and sent back to Global Breathing Awareness. Except in the case of extenuating circumstances, if I decide to stop my participation in this online program, or I do not show up for sessions with my mentor, I lose the session. If I want to start the program again at a later date, I may have to pay extra for sessions with a new mentor. In the case of extenuating circumstances I can liaise with GBA/RBT staff to inform them or send an email to support@katiaboustani.com Global Breathing Awareness reserves the right to cancel programs, change program location, change instructors, or change program content. In the event that a program must be canceled, registrants will be informed 30 days prior to the start of the program. If the Global Breathing Awareness cancels a program, the full amount will be refunded. [1] If you bought a product or a service online or outside of a shop (by telephone, mail order, from a door-to-door salesperson), you also have the right to cancel and return your order within 14 days, for any reason and without a justification. https://europa.eu/youreurope/citizens/consumers/shopping/guarantees-returns/index_en.htm [2] You have the right to cancel and return your order within 14 days, for any reason and without a justification. This "cooling off" period expires 14 days after the day you received your goods (or concluded a contract for services). However, the 14-day cooling off period does not apply to all purchases. Some of the exemptions are: 1. online digital content, if you have already started downloading or streaming it and you agreed that you would lose your right of withdrawal by starting the performance. https://europa.eu/youreurope/citizens/consumers/shopping/shopping-consumer-rights/index_en.htm#changed-mind-distance-1 CONFIDENTIALITY AGREEMENT I agree to respect the confidentiality of all participants in the Global Breathing Awareness/ RBT program Levels 1 and 2 — their names and their remarks — so that their participation and their communication are not taken out of context. I am also aware that the handouts, exercises and articles of the RBT program cannot be duplicated without express written permission of Katia Boustani. This agreement does not preclude me from freely sharing my experience with anyone I choose, as long as the confidentiality of the participants is maintained. I agree to not share my username and password with anyone else before, during, or after this program. Whether participating in the seminar in person or online, I agree not to record, distribute or post on social media any of the material, lectures, sessions or online sessions without the consent of GBA/RBT and the other participants. All information shared during the seminar, written or verbal, becomes the confidential property of Global Breathing Awareness. This information may be used in writing books, articles or video documentaries, but will in no way identify me. Global Breathing Awareness reserves the right to terminate this contract and my participation in the seminar at any time. I understand and consent that in some seminars there may also simultaneously be an in-person component with interaction with participants who are attending the training online. (Please state “agree” or “disagree”): I agree to the above terms and conditions.