I the undersigned acknowledge that there is some inherent risk involved when participating in or engaging in a seminar which involves walking across burning embers.  I declare that I am of sound mind and relinquish from liability in any way shape or form from me or any party acting for me, the company I work for, Success Formulae Limited, its Directors, associated companies, suppliers, employees or associated staff both now, or at any time in the future from any injury done by me or to me of whatsoever nature during my participation in this course.

I understand that the seminar is conducted so that I can benefit from the content within it and that I am under no obligation to firewalk or partake in any of the exercises within it and that if I do then I declare that I am participating in the seminar and firewalk of my own free will, voluntarily, and at my own risk and I also understand that no assurance guaranteeing my safety is being made.

I understand that people have been injured by participating in firewalking and/ or glasswalking/ type seminars and that there is inherent risk in these types of activities which often provides their unique appeal and that if I voluntarily choose to firewalk, there is a possibility that I might receive injuries requiring medical attention.

I agree not to bring any suit for damages and I release all parties associated with this event from any damages suffered by me whether mental, physical or financial.

I understand fully that I am solely responsible for all my choices during the event, and have been warned against the intake of alcohol or mind altering drugs. I am over 18 years of age and competent to sign.

I attest that I have no physical conditions which may inhibit healing, such as diabetes, auto-immune diseases, or any other medical condition which might adversely affect my physical and / or mental wellbeing in the event of injury.  I further affirm that I do not desire to inflict harm upon myself.

By signing this form, I release the aforesaid parties from any and all claim(s) I may have while attending this event.  I am knowingly and voluntarily assuming any and all risks of injury including death, and am knowingly and voluntarily signing this release form.

My signature below specifies that I have read and understood everything contained in this waiver and assumption of risk form.  I have read this entire Release Form and fully understand it and agree to be bound by its contents.

THIS WAIVER IS A RELEASE OF YOUR RIGHTS. PLEASE READ CAREFULLY BEFORE SIGNING