Registration Form

Please print this page and fill it out, then mail the printed form with the check to ensure your enrollment.

After reading the disclaimer please sign and date to indicate that you fully understand it.
Then return to

Gerlinde H. Gelina

PO Box 11331

Shorewood , WI 53211

Please call me if you have any questions.

Waiver and release
Please read all of the following before signing

Systemic and Family Constellation Workshops, Systemic Group Training and Systemic Personal Coaching are programs for unmasking the hidden dynamics found in associated groups, families, and within individuals with the goal of disentangling emotions. Systemic Personal Coaching is a program of personal coaching designed to promote professional and personal improvement.

The word “Program” as used hereinafter shall refer to Systemic and Family Constellation Workshops, Systemic Group Training, and Systemic Personal Coaching, individually or in any combination together.

Gerlinde H. Gelina reserves the right to accept or reject any person as a participant in the Program at any time, and to make changes in the Program and how it is conducted whenever deemed necessary by her for the comfort, convenience and safety of the participants, and to cancel a Program at any time. In the event a Program session must be canceled, Gerlinde H. Gelina shall have no responsibility to any participant beyond the refund of monies paid to her by participants for the canceled part of the Program. By registering, the participant agrees that Gerlinde H. Gelina shall not be liable for any damages, loss or expense occasioned by any act or omission by her or any other Program participant.

By signing below, I state the following:

1. That I am reasonably healthy, both mentally and physically, and that I currently do not suffer from any diagnosed psychological disorder.

2. That I will participate in this Program of my own free will.

3. That I understand the Program to be a training, educational and self explorative process.

4. That I understand that the Program is not psychological or psychiatric therapy and that it is not intended to replace such types of therapy or therapy of any other kind.

5. That I understand the objective of the Program is educational and not psychotherapeutic in nature.

6. That I understand issues may be addressed in the Program which may be of a highly personal and emotional nature and that I may experience or observe emotional or physical manifestations, in myself or in others, and that I consider myself reasonably healthy, physically, mentally, and emotionally, to experience such manifestations.

7. That if I previously may have suffered or actually did suffer from a psychological disorder, I have given this fact consideration and believe that I am now in a position to participate in the Program.

8. That I understand that actual participation in a constellation procedure is at the sole discretion of the Gerlinde H. Gelina and that her decision is final.

9. That I understand there is no guarantee of results from participating in the Program, either explicit or implied.

I have read and understand all of the above. By signing this waiver and release, I assume the risk of any damages or injuries, real or imagined, which I may sustain as a result of participating in the Program. I do hereby remise, hold harmless and release, and forever discharge Gerlinde H. Gelina and/or her affiliates, employees, support staff and other training participants as well as the training facilities, their owners, management and assigns, from any and all claims, suits, demands or actions arising from or growing out of my participation in the Program.
I further agree to respect the confidentiality of any personal disclosure made within the course of Program participation and will not discuss any such personal details outside the meeting space. This waiver and release shall be binding upon my heirs, assigns, guardians, and legal representatives.

Signature _______________________________Date __________