Consent Form

Consent Form

 

 

Fields marked with a * are required.

I enter into this Agreement with CHIQUITA MONTGOMERY also known as Gogo Ekhaya Esima and Sangoma Healing (hereinafter collectively referred to as “Montgomery”), to confirm in this Agreement the conditions of my participation in the /divination/reading/healing/clearing/ritual assistance hereafter referred to as 'service' to be performed by Montgomery. I acknowledge that I have voluntarily agreed to participate and request Montgomery to perform this service. I am aware that my participation in this service is not a substitute for psychiatric treatment, psychotherapy, therapeutic counseling, medical treatment or any other form of professional therapy. I am voluntarily participating in this service and I accept complete responsibility for my own psychological, mental, emotional, physical and spiritual well-being. I acknowledge that it is my responsibility to ascertain my own need for professional counseling and to seek such professional counseling or treatment, as needed. For and in consideration of my voluntary participation in this service, I, on behalf of myself and my assigns, heirs, executors, guardians and other legal representatives, release, discharge, waive and forever relinquish Montgomery (including Montgomery's agents, employees, officers and directors) from any and all claims, known or unknown, arising out of or in any way connected with my participation or involvement in this service including, but not limited to, any information provided to me or statements made during such reading and/or healing. Further, I, on behalf of myself and my assigns, heirs, executors, guardians and other legal representatives, release, discharge, waive and forever relinquish any actions or causes of action whatsoever which may later arise, and I agree that under no circumstances will I or my assigns, heirs, executors, guardians and other legal representatives, prosecute or present any claims against, sue or seek to attach the property of Montgomery (including Montgomery’s agents, employees, officers or directors), and that I waive all actions, claims or demands that I now or hereafter may have, for any injuries suffered by me during my participation or involvement in the reading and/or healing, resulting from any acts or omissions of Montgomery, or any agent, employee, officer or director of Montgomery, or resulting from the acts or omissions of any other participant in the service. I, for myself and my assigns, heirs, executors, guardians and other legal representatives, hereby agree that in the event any claim for damages shall be prosecuted against Montgomery (or Montgomery’s agents, employees, officers or directors) as a result of my acts or omissions, that I, or my estate, shall indemnify and save harmless Montgomery (including Montgomery’s agents, employees, officers or directors), from any and all claims or causes of action by whomever and wherever made or presented for damages, including the cost and expense of defending the same. I further acknowledge and understand that any information provided during this service or any other statements made during same shall be considered confidential and shall not be disclosed except as required by law. I have carefully read this Agreement and fully understand its contents, terms and significance and understand the legal consequences of signing this Agreement. I am aware that this Agreement contains a release of liability and a contract between myself and Montgomery and I sign this Agreement of my own free will.
Please check this box to indicate you have read, accept and agree to abide by the terms and conditions listed above (required).