Seminar (Course) Application and Declaration of Responsibility

You will get the following statement printed during the registration before the seminar.

 

 

Seminar (course) application

and declaration of self-responsibility

(please fill in this form with capital letters)

 

I,.................................................................…

(name, surname)

 

year of birth ...................................................

 

address (with ZIP code)..................................

 

....................................................................

 

phone:............................................................

 

email:...............................................................

 

hereby pronounce that I participate in the seminar/training::

 

........................................................…............

(its name and date)

 

held by Mrs. Zdeňka Tušková, reg. no.: 64872076, with registered office at Prague 4, Mojmírova 1739/8, ZIP code: 140 00, Czech Republic, and Equilibrium s.r.o., reg. no.: 26419467, with registered office at Prague 4, Mečislavova 208/4, ZIP code: 140 00, Czech Republic.

 

By signing this statement, I expressly declare that I participate voluntarily, solely on my own responsibility, that I am an adult, that I am legally competent, and that I am eligible for legal negotiation and that this legal capacity is not limited in any way. By signing this statement, I expressly acknowledge that I am fully aware of the fact that I am fully and solely responsible for myself throughout the seminar, and that the lecturer's instructions are only suggestions that I will follow solely at my own discretion, and that I can voluntarily decide whether to engage actively in the course or to remain a passive participant. At the same time, by signing this statement, I declare and confirm that I am well acquainted with my state of health and this does not prevent me from attending the seminar. At the same time, I am fully aware of the fact that the seminar is not a substitute for any medical care (including psychotherapeutic) and that the lecturer does not provide this care. I further declare that at present I am not psychotherapeutically, psychiatrically or similarly medically treated. If I undertake any kind of treatment or therapy at this time, or if I undertake any of the above mentioned treatments or therapies during the seminar, I undertake to immediately inform my attending physician or psychotherapist about the attendance of this seminar and the seminar lecturer about her treatment and/or therapy. By signing this statement, I expressly agree that the lecturer of the seminar is entitled to terminate my attendance at this seminar at any time, without giving any reason, and in such a case I agree that I will be refunded a relative price paid for the seminar. I also acknowledge and expressly agree that, if I decide to leave the seminar myself prematurely, I will not be refunded any part of the price paid for the seminar. I am aware of the fact that attending the seminar does not claim to have my own constellation.

 

By signing this statement, I confirm that I have been made aware of the privacy and data protection principles that form an integral part of this application.

 

 

I give my consent to be sent newsletters or bussiness communications:  YES  NO

 

 

 

In.....................................on..........................

 

Signature ..............................…