Assumption of Risk Intake Form

Agreement Regarding Assumption of Risk, Indemnification, and Release for Training & Program Participants, Presenters, Leader Trainers and Facilitators

First name

Last name

Phone

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Multi-line address

Country/Region

Address

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Emergency Contact Name

Emergency Contact Phone

Congratulations on your decision to participate in the Gender-Inclusive Facilitation Training (GIFT)! The purpose of this document is to ask you to commit to taking personal responsibility for your safety and well-being.

The GIFT is for people who want to learn how to facilitate others and who plan to use these facilitation skills in their own non-commercial group meetings. The "weekend intensive GIFT" takes place on Friday evening and two full days on one weekend. You will have the opportunity to learn and practice processes that will help you safely facilitate others in a group format. We require that during our time together that you refrain from alcoholic beverages and non-prescription mood altering drugs.

The ManKind Project as a matter of integrity and accountability wants me to know in advance of the inherent or potential risks of the Training and the associated Activities.

I understand that the ManKind Project will take reasonable steps to seek to provide a safe environment. However, I also understand that certain risks are inherent in the Training and cannot be eliminated without destroying the unique character of the Training and the Activities.

I understand and agree that the ManKind Project is not and cannot be a guarantor or insurer of my safety or well-being.

I agree to act with reasonable care for my well-being and the well-being of all other people and property around me during the Training and the Activities.

What made you desire to take this training?

Describe your support network (partner, friends and relatives) you can talk to:

What do you do for self-care?

List the names of all the medications/drugs you take regularly

Describe any mental health issues you have that may create problems for you or others

Describe any physical issues you have that could create problems for you or others

List every food and medicine you are allergic to, and any other allergies you have

List any dietary needs you want us to be aware of

Describe any addictions you have that could create problems for you or others

Have you attempted suicide in the past 2 years?

Yes

Have you been hospitalized for a psychiatric illness in the past 2 years?

Yes

I attest that I do not have any medical, physical, mental, or emotional condition which prevents me from safely participating in the Training and Activities.

I also understand that I am solely responsible for my health and welfare with respect to any medical, physical, mental, or emotional condition, whether disclosed or undisclosed, and will take all reasonable precautions that may be necessary for my safe participation.

If I have or suspect that I may have any condition that may pose any danger to myself or others, I will immediately and fully disclose this condition to the Training leaders.

By signing this document you are acknowledging that there are risks associated with attending a GIFT as well as risks when facilitating others both during the training as well as with other personal growth groups outside of this training. Your signature also acknowledges that you:

Have sought the opinion of your health care professional (if that is applicable)
Are voluntarily assuming those risks
Are committing to look after yourself during the training
Will take personal responsibility for your own safety and the safety of others both during this training as well as when you facilitate others outside of this training
Have disclosed all physical, psychological and psychiatric conditions that may impact your participation.
Are not a reporter, filmmaker, researcher, or similar individual attending solely or largely to report on or research our group or personal growth work in general.

Signature

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I have read and agree to abide by the ManKind Project policy on Ethical Relationships at: https://www.mankindproject.ca/ethical-relationships

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