Please fill out the form below with your information

By providing my phone number and email, I agree to receive text messages and emails from Jed Elton.

For your safety & the safety of the group, if you experience any of the following, you must talk with Jed (facilitator). Do not breathe without a conversation first. Please call Jed at 801-380-5680

-Pregnant

-Detached Retina

-Glaucoma

-High Blood Pressure (not controlled with medication)

-Cardiovascular Disease including angina, previous heart attack, or stroke.

-Diagnosis of aneurysm in the brain or abdomen

-Asthma - if you are asthmatic, you need to have your inhaler available.

-Epilepsy

-Prior diagnosis of bipolar disorder, schizophrenia, or previous psychotic breakdowns.

-Hospitalization for any psychiatiric condition or emotional crisis within the last 2 years.

-Any other medical, psychiatric, or physical condition which would impair or affect the ability to engage in any activities that involves intense physical and/or emotional release.

I CONFIRM THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION, AND HAVE ANSWERED ALL QUESTIONS COMPLETELY AND HONESTLEY, I HAVE NOT WITHHELD ANY INFORMATION. 

MY GENERAL HEALTH, AS FAR AS I AM AWARE, IS GOOD.


"I AGREE TO FULLY RELEASE & HOLD HARMLESS W. JED ELTON FROM AND AGAINST ANY AND ALL CLAIMS OR LIABILITY OR WHATSOEVER KIND OR NATURE ARISING OUR OF OR IN CONNECTION WITH, DIRECTLY OR INDIRECTLY, FROM THEIR SERVIECS AND SESSION(S)"


I HAVE READ THE ABOVE INFORMED CONSENT, UNDERSTAND, AND AGREE TO IT.

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