Request for KMCSRO PARTICIPATION AND Release of Liability Form

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This is a Formal Request by _____________________________ on behalf of ___________________________________________________________________________ petitioning for consideration of KMCSRO Service(s). This request is voluntarily sought for obtaining  __________________________________________________________________ services from KMCSRO. I am a ____________________ of KM. I HAVE READ AND REVIEWED ALL disclosures, rules and expectation moral compass codes of ethical conduct standards and AGREE to respectfully abide by them while receiving service offerings and or engaging with service offering providers while I am actively participating in/ receiving such service offerings. I agree to respect all individual and collective boundaries of each participant and to report when my own are not respected accordingly.

I authorize the provider to use disgression in providing service offerings to make and keep record of all communications including electronic, personal and third party etc. by audio, video and any other feasible means as appropriate and applicable as outlined in the KMCSRO Structural code.

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This RELEASE and Waiver of LIABILITY is made and entered into on this __________ day of _______________, 20_____, by and between the  ___________________ (hereinafter designated Provider) and _________________________________ (hereinafter designated Initiating Client); and, if the Client is a minor, the Child's/ Children's name(s)_________________________________________________________________________________________________________________________________________________________
(If the PARTICIPATING person a minor child, said person Must Be a parent or guardian of the child(ren) who Completes, Signs and Submits this request for KMCSRO service offering consideration application/participation form. 

As a precondition to any and all counseling services to be provided by the counselor, the undersigned, in consideration of the services provided by KMCSRO, both parties acknowledging the adequacy of said consideration, does hereby remise and release from any and all injuries, losses, damages, liabilities, defenses, claims, actions, causes of action, suits, debts, promises, demands, or agreements, of whatever nature or kind, known or unknown, whether based in law or in equity, that either party hereto ever had or now has or that any one claiming through or under either party may have or claim to have, which was raised or asserted or could have been raised or asserted against the other party at any time prior to the execution of this agreement, including, but not limited to, any and all claims arising out of, by reason of, or in any way related to the subject matter of the counseling relationship/services as a direct or indirect result of any involvement Client may have with the counselor or the counselor’s church  or any other partnering/hosting church. 

Client further understands that it is the specific intent and purpose of this legal document to release and discharge any and all claims and causes of action of any kind or nature which are directed toward a Counselor, Provider or Church. This includes causes which are known or unknown, specifically mentioned or implied, or not mentioned nor implied, which might exist or be claimed to exist at or prior to the date of this document.
 The undersigned further specifically waives any claims or right to assert that any cause of action or claim or demand has been, through oversight or error, intentionally or unintentionally omitted from this release. 

The undersigned also understands that the provider is a certified spiritual provider approved by the Elder Council of the whole of KM and/or has been trained in counseling services, but is not necessarily state licensed Counselor, Therapist, or Psychotherapist and not under the regulatory authority of any governmental agency. 

Also, when the term counseling or counselor is mentioned above it does not refer to psychiatric or psychological state licensed professional, psychiatric, legal or clinical medical advice provider. The advice given is based on how to think rationally and clearly from a KM Spiritual and human rights perspective only. The nature and source of all information given comes from the Great Creator (Kautantowit) and therefore is Spiritual and Pastoral counseling or sometimes referred to as Life Coaching,  Religious Counseling, or so forth.

I HAVE READ AND UNDERSTAND ALL OF THE ABOVE.
Participant Signature _____________________________________________ Date___________

Printed Name: ____________________________________________