Application for Fasting

Assumption of Risk, Release, Waiver of Liability, and Covenant Not to Sue

PART I: ASSUMPTION OF RISK

I intend to participate in a program entitled Fasting in Costa Rica, a retreat from in San Gerardo, Costa Rica (hereafter "Fasting CR") conducted by Dr. Douglas Graham, and his staff (hereafter the "Graham Group") in association with Rio Chirripo Retreat Center, Staff and Frank Faiella, Owner (hereafter "Rio Chirripo"), and I acknowledge that participation in any lifestyle program may involve inherent risks of physical injury, possibly including, but not limited to, broken bones, strains, sprains, bruises, concussion, heat-related illnesses (hyperthermia), abnormal heart beats, abnormal blood pressure, drowning, and in rare cases, a heart attack, stroke, and possibly death.

I further acknowledge that I am solely responsible for any hospital or other costs arising out of any bodily injury or property damage sustained through my participation at Fasting CR.

I have read and understand this notice. By signing this form, I accept and assume all risks, hazards, and dangers - known and unknown, foreseeable and unforeseeable - involved in any such activities in which I may elect to participate at Fasting CR, including the training for, preparation for, residing within, and travel to and from the sites of such activities.

PART II: INFORMED CONSENT

The purpose of this document is to inform you of the some of the risks associated with water-only fasting, so that you can make an informed decision on whether to choose to do a water-only fast. The choice to do a water-only fast is your independent decision; you should weigh the benefits and risks of a water-only fast and come to an informed decision.

This document is only one part of the process of informing you of the risks of water fasting. It is not, by any means, the only part of the information process. Discussions with, and questions to, the involved chiropractors or medical doctor associated with Fasting CR, and with other healthcare providers outside of Fasting CR, are an important part of this informational process. Reading materials, audiotapes and videotapes, are also an important part of this information-gathering process. We strongly encourage you to ask any and all questions, and to satisfy all your informational needs, prior to your decision to undergo a water-only fast. We also encourage you to discuss your decision on water fasting with any healthcare provider not affiliated with Fasting CR, including your regular physicians.

First, Fasting CR is not a hospital, or medical care facility with a staff of doctors, nurses, etc. It is a health education program, where participants can reside in its rooms for a short period of time while participating in its programs. Fasting CR has independent doctors of chiropractic, medicine, and psychology who make themselves available to assist in its programs. But, please be clear that if you have any problems with the fact that Fasting CR is not a hospital or a medical care facility, then you should not undergo a water-only fast with us.

Fasting CR also compiles medical data obtained from its participants, analyzes this data, and publishes articles regarding this data and research in journals, books, and lecture materials. These articles do not reveal the identities of any of the participants, but rather only identifies, summarizes and analyzes the medical data. If, for some reason, you have any problems with the fact that Fasting CR compiles data based upon your medical information, and publishes that data, then you should not undergo a water-only fast with Fasting CR.

Next, you should be clear that chiropractors and naturopaths will be assisting you during your fast. These doctors are not medical doctors. There is a medical doctor, who is on call to us, but you will probably be seeing only our staff doctors. These doctors will have access to your medical records. If you have any problems with the fact that there are not medical doctors on the premises to assist you throughout the majority of your water fast, then you should not under go a water-only fast at Fasting CR.

Next, while you are water-only fasting with us, there are no medical doctors present during the evenings or at night. There is a staff person present on site throughout the evenings and night. Your medical records will be available to this staff person. If this is a problem, please let us know, or consider not fasting with us.

Next, you should be clear about the basic definition of a water-only fast: A participant undergoing a water-only fast is consuming only water for the length of the water-only fast.

You should know that water-only fasting is not accepted by the vast majority of medical doctors and other healthcare providers, including nutritional and dietary experts. These medical doctors and other healthcare providers believe that water-only fasting has too many risks, which outweigh any possible benefits. It is only a very tiny minority of healthcare providers who accept water fasting as a valid process.

There are many risks to water-only fasting and we want you to be aware of them prior to your decision to undertake a water-only fast. Because you will not be eating any food, you will most certainly experience weakness throughout the water fast, and lose weight. It can take some time after fasting to regain strength. A very common occurrence is dizziness and fainting, especially on rising from a laying or seating position. Other common and unpleasant symptoms are heart arrhythmia, palpitations, dehydration, nausea, vomiting, skin rashes, sore throat, mucus discharge, low back pain, increased menstrual flow, irregular or anovulatory cycles, hair loss, gastric irritation, passing of kidney or gall stones and emotional disturbances. There is also the possibility of alterations to your body's basic mechanisms and electrolytes, which could cause heart problems such as a heart attack or vascular problems such as a stroke.

We cannot and do not guarantee that the water fast will benefit the health condition that you are seeking to improve.

You should also know that there are alternatives to water fasting, which you are welcome to discuss with any staff member of Fasting CR, or with any medical doctor, chiropractor, or other healthcare provider not affiliated with Fasting CR. One alternative is obviously to decide not to do a water-only fast. Please be clear that we want you to choose to do a water-only fast only if it is your independent decision. Other alternatives are to undergo a modified fast with the continued consumption of fresh juices and broth or to continue to eat a health promoting diet while participating in our residential health education program. Other doctors or healthcare providers may have other alternatives to water-only fasting, and you are encouraged to consult with them.

Please be clear that you can decide not to do a water-only fast, or discontinue fasting at any time. Do not hesitate to stop the water-only fast, at your discretion, at any time during the fast. Simply inform us of your desire, so that we can implement that decision.

We request that you agree to stay on our property at all times during your water-only fast. Persons fasting must also agree to remain with us for a period no less than half the length of their actual fast - for refeeding. For example, if your fast lasts two weeks, you must agree to remain with us for an additional week for refeeding. This requirement is for your protection as the recovery from water-only fasting can be a delicate matter.

All participants must pay for all services at the time they are rendered.

I, THE UNDERSIGNED, HAVE BEEN INFORMED OF, AND UNDERSTAND, THE NATURE, RISKS, AND POSSIBLE COMPLICATIONS AND CONSEQUENCES OF WATER-ONLY FASTING. I CHOOSE AND CONSENT TO UNDERTAKE A WATER-ONLY FAST.

I HAVE BEEN ENCOURAGED TO ASK QUESTIONS AND ALL OF MY QUESTIONS HAVE BEEN ANSWERED. I HAVE NEVER ASKED FOR NOR RECEIVED ANY GUARANTEES OR PROMISES FROM ANYONE AT FASTING CR AS TO THE RESULTS WHICH WILL BE OBTAINED.

THIS INFORMED CONSENT FORM HAS BEEN EXPLAINED TO ME, AND I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND ITS CONTENTS AND DO CONSENT TO A WATER-ONLY FAST EVEN IN LIGHT OF THE RISKS OF A WATER-ONLY FAST.

PART III: RELEASE, WAIVER OF LIABILITY, AND COVENANT NOT TO SUE

For myself, my heirs, executors, administrators, and assigns, I agree - for the additional consideration of the enrichment I expect to derive from the Fasting CR program and for the consideration of the Graham Group allowing my participation in the program - to waive, release, hold harmless, covenant not to sue, and forever discharge the Graham Group and/or Rio Chirripo, and their members and entities individually, their officers, agents and employees and staff, from any and all claims, demands, rights, causes of action, judgements costs and expenses, or other liability of whatsoever kind or nature, including gross negligence of the releasees and/or others, resulting from my participation in or growing out of or in any way connected with Fasting CR either arising before, during and/or subsequent, including but not limited to any and all, known and unknown, foreseen and unforeseen, bodily and personal injuries, including death and its consequences.

I hereby certify that I am at least 18 years of age, or am represented by a parent or guardian, that I am suffering under no legal disabilities, and that I read this form carefully, understand it, and agree to be bound by its terms. I also acknowledge that I have asked a member of the Graham Group all questions that I have concerning this document, if any, and, if so, that my questions have been answered satisfactorily.

I also agree that any audio or video recordings or written notes I capture during this event are for my own personal use, and will not be put to any commercial use, whether or not a fee is charged.