Green Juice Form

Please complete this form to participate with the “Green Juice” detox program.

Name *
(food, drink, topical, scents...)
Please describe... (This information is confidential.)
(This information is confidential.)
Release & Liability Waiver
In consideration of being allowed to participate in the activities and programs, and in consideration of the voluntary nature of such participation and use, I hereby release, hold harmless, and forever discharge Apollonia Fortuna, SoHA, Inc, Awareness Studios, LLC, Holding Consciousness, LLC, and/or Vibrancy, LLC, its employees and agents, from any and all liability, claims, demands, actions, and causes of actions whatsoever arising out of or related to any loss, property damage, or personal injury, including death, that may be sustained by me or to any property belonging to me, while participating in such activity. I understand and am aware that participating in detoxing activity including: colonics, enemas, detox drinks and food, and the use of any/all equipment, are potentially hazardous activities. I also understand that detoxing activities involve a risk of injury and illness, and that I am voluntarily participating in these activities with knowledge of the dangers involved. I hereby agree to expressly assume and accept any all all risks. I do further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness (physical or mental) that would prevent my participation except as hereinafter stated my forms. I acknowledge that I have either had a physical examination and been given my physician’s permission to participate, or that I have decided to participate in detox activity without the approval of my physician and do hereby assume all responsibility for my participation in my detox activities. I agree to comply fully with the rules/regulations and directions provided by the staff of any SoHA, Awareness Studios, LLC and/or Vibrancy, LLC training programs. Further, I understand that I will be disqualified from the activity in the event that I fail to comply with said rules.
Signature & Date *
Typing my name here acts as my signature. *
Typing my name here acts as my signature.
Today's Date *
Today's Date