Native American Indigenous Church (N.A.I.C.) Inc. PARTICIPANT MEMBER ACTIVITY CONSENT, DISCLOSURE, WAIVER, AND DISCLAIMER FORM I request that (Rev. Dr. Elizabeth SoulFire (Harrell), to perform Native American, Indigenous traditional Religious Therapeutic: Healing and or related: (SomaVeda® Thai Yoga/ Indigenous, Indigenous Traditional Thai Massage/ Nuad Boran, Jap Sen Nuat, Tapping, Ayurveda, Yoga, Tantra and or sacred expression of natural healing in session, evaluation, therapy, consultation, Indigenous (clerical/ pastoral/ ministerial) Healthcare-Healing Science, Counselling, and Medicine (I.H.C.M.), or to set up program/ programs (or have sessions, etc.) for the purpose of (tending and caring for the sick, infirm, blind, broken, diseased persons, counselling, educating, sharing, expressing and/ or practicing Religious Therapy: Native American Medicine, Ritual, Ceremony, Medicine/ Healing and or related indigenous, traditional earth based healing modalities such as Ayurveda, Yoga, Yoga therapy, SomaVeda® Thai Yoga, Indigenous Traditional Thai Yoga, Traditional Chinese Medicine, Nature Cure, Traditional Naturopathy, sharing/ expressing of love, compassion, joy and equanimity, as well as conversations regarding our mutual physical, mental, emotional or spiritual health and wellness including diet, Sacred Nutrition, Holistic and balancing Nutrition and any appropriate exchanges mutually agreed upon, using established procedures and methods approved by the Native American Indigenous Church, Inc. FBO/ Tribal Organization DBA N.A.I.C., Inc.).
I understand religious therapeutic sessions may or may not involve ceremony, prayer, physical pressure (anointing), facilitated movement, “laying on of hands” (Chirothesia), emotional, mental, psychological, or Bible-based Christian or Christ-Centered Native American Religious, spiritual counseling or exercises. I understand that Rev. Dr. Harrell has a (certification, degree, religious authorization or training) from NAIC: The Thai Yoga Center, or recognized N.A.I.C. seminary/ school located in the state of Florida or school/ Minister, Certified Teacher approved by N.A.I.C., Inc. I understand that any of the sacred healing practices (religious therapeutics) we share (sacerdotal duties) and or express in private are not intended as diagnosis, prescription, or treatment for any disease, physical or mental, as defined by applicable state medical and or Massage/ Massage Therapy practices acts. It is also not intended to substitute regular medical care by a licensed medical provider. I understand that all services/expressions, regardless of the names or titles used to describe them: Aboriginal/ Indigenous Healing, Native American Healing Medicine, Ceremony, Sacraments, SomaVeda Integrated Traditional Therapies®: Thai Yoga, Indigenous Traditional Thai Massage, Pancha Karma, Classical Ayurveda, meditations, affirmations, energy exchanges, prayers, Christ-Centered Yoga practices, therapies, sessions, protocols, Bio-Tapp/ EFT/Energy Psychology and or other sacred indigenous, traditional, natural, non-invasive, holistic practices and healing conversations are private practices conducted by authorized members of Private Religious Domain and Private Religious Faith Based Organization/ Membership Organization: NAIC, Inc. of which I am a member, and that I am NOT receiving these above-referenced services as a member of the public. I understand that NAIC, Inc. is a Private Religious/ Church Domain, Private, Religious Tribal Organization for the preservation, establishment, and practice of Religious Therapeutics, Native American, Indigenous (aboriginal) Traditional Medicine and Therapies, Reiki, Energy Balancing, Spiritual Counseling or related health, wellness and healing arts and sciences. In receiving these services, I agree to abide by the NAIC Articles of Religious Practice, education and Healthcare Membership, NAIC Code of Ethics, and NAIC Cancellation and Refund Policy as posted on the church website NativeFireChurch.Org (SomaVeda.Com). I understand that I do not need to be of Native American (aboriginal) heritage of origin to participate and or receive services from an NAIC Tribal organization authorized member/ provider/ minister/ therapist/ counselor. Access to Healing is a Human Right. I am an adult, aged 21 or older, or a parent of a minor child, legally and mentally competent to make informed decisions regarding my beliefs, religious/ spiritual practices, health, wellness, and recreation. I swear that all information I provided supporting receiving/ participating in services from the above-referenced practitioner is correct and accurate as a precondition for participating in private ministerial/ healing activities. NINTH AMENDMENT DECLARATION ARTICLE IX, U.S. CONSTITUTION “The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the People.” Under the Ninth Amendment to the Constitution of the United States of America, I retain the right to freedom of choice in health care (or psychological Services, educational services, etc.). This includes the right to choose my diet and to obtain, purchase, and use any therapy, regimen, modality, remedy, or product recommended by a fellow member therapist, doctor, or any practitioner of my choice. The enumeration in this declaration of these rights shall not be construed to deny or disparage other rights retained by me or my right to amend this declaration at any time. CONSTRUCTIVE NOTICE Notice is now given to any person who receives a copy of this Declaration and who, acting under the color of law, intentionally interferes with the free exercise of the rights retained by me under the Ninth Amendment, as enumerated in this declaration, that they may violate my civil and constitutional rights, Title 42, U.S.C. 1983 et seq. and Title 18, Section 241.
Cancellation Policy: Please contact me on this website, and/or at email@example.com at least 24 hours in advance of your appointment to notify us of any changes or cancellations.
By booking a session, you are signing this document, you hereby declare under penalty of perjury that you are over the age of 18 years old and legally able to enter into this agreement and do so of your own free will; and that you have ready, understand, fully and expressly agree to the Disclaimer, Informed Consent, and Waiver terms contained herein.
Please execute this instrument upon request.
Parent/Guardian Presence and Signature Required for clients age 18 and under.