PARTICIPANT RELEASE, CONSENT AND WAIVER OF LIABILITY

Welcome to Mindfulness 4 Success program(M4S) offered by Alliance Endocrinology PC. Please read this document and sign in.

Mindfulness and meditation practice is not a substitute for medical or mental health treatment. This is a basic three-week program without any intense physical work out. This includes very effective breathing exercises and simple mindfulness meditation. You are encouraged to verify with your health provider that your health and physical condition will allow you to safely participate in this program. You need to be ages 18 and above to participate in this study. In addition, if you are pregnant, become pregnant, or are post-natal or post-surgical, please do not participate in this program.

I authorize and consent M4S, Alliance Endocrinology PC to track my daily progress through this web app and use my pre/post survey questionnaire information for study purposes. I understand that this information is confidential and will not be disclosed without my written authorization except when otherwise permitted or required by law.

I affirm that I voluntarily consent to participate in this M4S program. I hereby agree to irrevocably release and waive any claims that I have now or may have here after against M4S, Alliance Endocrinology PC and its guides. I expressly agree that this release shall be binding upon my heirs, executors, administrators and assigns. By signing this waiver and read it in full and understand all its terms. I execute it voluntarily with full knowledge of its significance.

I Agree to the above PARTICIPANT RELEASE, CONSENT AND WAIVER OF LIABILITY

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