Name *

First Name

Last Name

Phone *

(###)

###

####

Today’s Date

MM

DD

YYYY

Release Agreement

I understand that Eden Energy Medicine is an innovative approach to health care, which is only beginning to be investigated scientifically. I further understand that the training in Eden Energy Medicine and other services I am or may be receiving from Marjorie Fein / Innersource, do not substitute for diagnosis and/or treatment from a qualified health practitioner for illnesses, injuries, or other medical conditions.

I understand that some classes are videotaped, that these tapes may be distributed for educational purposes, and I give my permission for my participation to appear on these tapes. Marjorie Fein/Innersource reserves the right, at its discretion and without explanation, to ask a student to leave an Eden Energy Medicine Certification Program class, to terminate a student from the EEM Certification Program, or to not graduate a student from the EEM Certification Program based on failure to meet the academic, behavioral, professional, or ethical standards of the program as determined by Innersource staff. Any refunds will be fairly determined, again at the discretion of Innersource staff, on a case-by-case basis.

I also understand that any activity in which a person might participate involves some risk. In consideration of being permitted to enroll for the instructional and other services offered through the Regional Education Program taught by Marjorie Fein /Innersource, I release and hold employees, directors, successors, and affiliated corporations harmless from any claims arising out of my participation in the instructional or other services offered by Marjorie Fein /Innersource/ Ascendance Holistic Healing.

By checking this box, you acknowledge that you understand and agree to the statements above.