For and in consideration of allowing me to participate in an educational support group hosted by 'Ai Pono Hawaii (Nova Luna, Inc.), I, for myself, and on behalf of my spouse, children, parents, guardians, heirs and next of kin, and any legal and personal representatives, executors, administrators, successors and assigns, hereby agree to and make the following contractual representations: I understand and acknowledge that this activity is not therapy and I am not a current patient of 'Ai Pono Hawaii. Thus, no client/therapist relationship is formed by my participation. The information provided to me is educational only and does not constitute the provision of medical or other professional health care treatment services. In exchange for allowing me to participate, I hereby waive and covenant not to sue, and further agree to indemnify, defend, and hold harmless, 'Ai Pono Hawaii and its officers, directors, partners, shareholders, members, agents, employees, contractors, and volunteers (collectively, the “Waived Parties”), from any and all liability, claim(s), demand(s), cause(s) of action, damage(s), loss or expense, including court costs and reasonable attorney’s fees of any kind or nature whatsoever (“Liability”) which may arise out of, result from, or relate to my participation. I further agree that if, despite this Agreement, I, or anyone on my behalf, make a claim for Liability against any of the Waived Parties, I will indemnify, defend, and hold harmless the Waived Parties from any such Liability which may be incurred as a result of such a claim that I might have against the Waived Parties or anyone associated with the educational support group. * Asking questions and sharing in the group is encouraged; therefore we ask that you keep all information discussed in this group confidential. This request means that you may not discuss patient’s or group member’s identity or identifying information, or share the reactions of any member of this group with anyone outside of the group. You may talk about your own personal reactions, and are even encouraged to do so outside of group, but not about others’ identifying information or reactions. Exceptions to confidentiality with regard to your group facilitator(s) include: imminent danger to self and/or others, child/elder abuse, subpoenaed records, and threat to national security. *

I understand all of the above and agree to the terms.

I understand that I am required to have my video function available and turned on throughout the group.

I will maintain the confidentiality of group participants and related parties

Name *

First Name

Last Name