​

 

To: The Integrative Restoration Institute                                                        Date___________________

​

I ______________________________________________ (the "Participant") hereby acknowledge that Donna Lynne Strong Brott LAcOM (the "Facilitator") is studying to become certified as an iRest teacher and I have volunteered to assist in that certification process by being part of a dyad co-meditation of iRest. 

​

I am aware that the sessions in which I will be volunteering will be recorded and that the recording will be shared with the Supervisors of Integrative Restoration Institute (IRI) for the purposes of assessing the effectiveness of the sessions led by the Facilitator. 

​

I hereby consent to the recording of the session by the Facilitator and the sharing of the recording with IRI Supervisors solely for the purpose o assessing the Facilitator's effectiveness in using the iRest protocol. 

​

I understand the the recording will not be used for any other purposes unless a further consent in writing is obtained from me. 

​

​

____________________________________________________                   _____________________________________

Signature of the Participant                                                                         Signature of the Facilitator