Name)
~~ a
Itkf ~
n fl~~
1
I
,
recognize,
acknowledge
and
agree
that
I
am
exclusivelyresponsible
for
my
presentandfuture
conditionin
life
and
for
the
choices
and
decisionsImake
affecting
my
life.
Withthat
in
mind,
and
solely
of
my
own
volition
and
in
the
independent
exercise
of
myown
free
will,
I
am
voluntarilysigningand
submitting
to
HUR H
OF
S IENTOLOGY
hereinafter
the
Church
this
GREEMENT
N
GENER L
RELE SE
REG RDING
SPIRITU L
SSIST N E
hereinafterthis Contract )
so
that,
upon
itsacceptance
by
the
Church.I
may
participatein
Scientology
ReligiousServicesandspiritualassistance
under
the
terms,conditions,
covenants,
waiversand
releasesIagree
to
by
signing
thiscontract,
andby
doing
so.Ispecifically
acknowledge
and
reaffirm
all
other
waivers,releasesandagreementsIhave
signed
with
any
Church
of
Scientology.2.ThisContractis
my
statement
ofmy
personal
understandingconcerningScientology
religioustenetsand
my
statementsreflecting
my
own
beliefs
and
desires.
Bysigning
thisContract,Irecognize,
acknowledgeandagree
that:
a.
Scientology
isareligion.theChurchisa
church
of
theScientology
religionandalltheservicesandactivities
of
theScientology
religion.are
exclusivelyreligious
innature.b.Scientology
is
unalterablyopposed,
as
amatter
of
religiousbelief,tothepractice
of
psychiatry,
and
espouses
as
areligiousbeliefthatthestudy
of
themind
and
thehealing
of
mentally
caused
illsshouldnotbealienatedfromreligionorcondonedinnonreligiousfields.I
am
infullagreementwiththisreligiousbelief.I
do
notbelieve
in
orsubscribetopsychiatriclabelsforindividuals.It
is
my
stronglyheldreligiousbeliefthat
all
mentalproblemsarespiritualinnature
and
thatthere
is
no
such
thing
as
amentallyincompetentperson
onlythosesufferingfromspiritualupset
of
onekindoranotherdramatizedby
an
individual.Ireject
all
psyr1iatriclabels
and
intendforthisContracttoclearlymemorializemydesireto
be
helpedexclusivelythroughreligious,spiritualmeansandnotthroughanyform
of
psychiatrictreatment,specificallyincludinginvoluntarycommitment
based
onso-called
lacl<
of
competence.Undernocircumstances,at
any
time,
do
Iwishtobedeniedmyrightto
care
frommembers
of
my
religiontotheexclusion
of
psychiatric
care
orpsychiatricdirected
care
regardless
of
whatanypsychiatrist,medicalperson,designatedmember
of
thestateorfamilymember
may
assertsupposedly
on
my
behalf.
If
circumstancesshouldeverariseinwhichgovernment,medical,orpsychiatricofficialsorpersonnel
or
familymembersorfriendsattempttocompelorcoerceorcommitmeforpsychiatricevaluation,treatmentorhospitalization,IfullydesireandfullyexpectthattheChurchorScientologistswillintercede
on
my
behalftooppose
such
effortsand/orextricatemefromthatpredicament
so
my
spiritualneedsmay
be
addressedinaccordancewiththetenets
of
theScientologyreligion.
c As
I
so
stronglydisagree.
as
amatter
of
religiousprinciple,withthe
use
of
psychiatrictreatmentforanyone,includingmyself,Irejecttheusage
of
psychiatriclabelsandIbelieveinassistingindividualsthroughreligious
and
spiritualmeans.Therefore,IamherebyspecifyingthatshouldI
get
intoasituationinthefuture,unlikely
as
it
is
whereothersmaythinkthatIneedpsychiatrictreatment
of
anykind.thatIinsteaddesiretoreceiveScientologyspiritualassistanceandthat
it
can
include.but
is
notlimitedto,theIntrospectionRundown.
Further
Irealizethatinthefuture
it
mayconsequentlybesuggestedbyaseniorScientologyminister,shouldtheneedarise,thatIreceive
such
spiritualassistance.andagain,Iwanttomake
it
dearthatunder
such
circumstancesIdesiretoreceiveScientologySpiritualAssistance,whichmayinclude,butnot
limitedto,theIntrospectionRundown.
d
The
Scientologyreligionteachesthatthespirit
canbe
savedandthatthespiritalone
may
save
or
healthebody,andtheIntrospectionRundown
Is
Intended
to
savethespirit.IunderstandthattheIntrospectIonRundown
is
an
intensive,rigorousReligiousServicethatincludesbeingisolatedfromallsources
of
potentIalspiritualupset,
induding
but
not
limited
to
familymembers,friends
or
others
withwhom
I
might
normallyinteract.Aspart
of
theIntrospectionRundown,Ispecificallyconsent
to
Churchmembersbeing
with
me
24
hoursaday
at
thedirection
of
my
Case
Supervisor,inaccordance
with
thetenetsandcustom
of
theScientologyreligion.The
Case
Supervisorwilldeterminethe
time
periodinwhichIwillremainisolated,according
to
thebeliefsandpractices
of
theScientologyreligion.Ifurtherspecificallyacknowledgethattheduration
of
anysuchisolation
Is
uncertain,determinedonly
by
my
spiritualcondition,
but
thatsuchduration
will
becompletelyatthediscretion
of
the
Case
Supervisor.Ialsospecificallyconsent
to
thepresence
of
Churchmembersaroundthe
dock
forwhateverlength
of
time
isnecessary
to
performtheIntrospectionRundown sprocessesandtoachievethespiritualresults
of
theIntrospectionRundown.Iunderstand,acknowledgeandagreethattheIntrospectionRundownaddresses
only
theindividual sspiritualneedsandIfreelyconsent,
without
reservation,and
wIthout
condItion
or
limitation,
to
ChurchmembersconductingtheIntrospectionRundown,andthatIacceptandassumeallknownandunknownrisks
of
inJury.loss,
or
damageresultingfrom
my
decision
to
participateintheIntrospectionRundownandspecificallyabsolveallpersonsandentitiesfromallliabilities
of
anykind,
without
limitation,associated
with
my
participation
or
theirparticipationin
my
IntrospectionRundown.
I
HAVE
CAREfULLY
RlAD
THIS
CONTRACTAND
fULLY
UNDERSTAND
ITS
CONRNTS
AND
CONSEQUENClS
I
ALSO
UNDERSTAND
THAT
I
AMNOT
ELIGIBLE
fOR
SPIRITUALASSISTANCE
UNLESS
I
SIGNTHIS
CONTRACT
WHILE
IT
IS
UNLIKELY
THAT
I
WILL
EVER
BE
IN
ACONDmON
WHERl
PSYCHIATRIC
INnRVlNnON
MAY
BE
DEEMED
AN
OPTION
I
HEREWITH
REAmRM
THATIN
SUCHAN
EVENT
I
WISH
TO
RECEIVEONLY
SCIENTOLOGYSPIRITUALASSISTANCE
INCLUDING
BUT
NOT
LIMIRD
TO
THE
NTR SPECnON
RUNDOWN
AND
THAT
THIS
CHOICE
IS
AN
INDEPENDENT
EXERCISE
f
MY
OWN
fREEWILL
I
fULLY
UNDERSTAND
THAT
BY
SIGNING
BELOW
I
AM
FOREVER
GMNG
UP
MYRIGHT
TO
SUE
THE
CHURCH
ITSSTAFF
AND
ANY
OF
THE
RELEASElS
NAMEDIN
THE
GENERALRELEASE
I
SIGNED
fOR
ANY
INJURY
OR
DAMAGE
SUFFEREDINANY
WAY
CONNECTED
WITHSCIENTOLOGYRELIGIOUSSERVICES
OR
SPIRITUALASSISTANCE
IsignthisAgreementandGeneral
Release
RegardingSpiritualAssistanceonthis
day
of
,
2 _
intending
to
be
legallyboundbyit,andrequestthatIbepermitted
to
participateinspiritualassistance.
SIGN TURE
OF
APPLICANT) Printed
Full
Name) HomeAddress)
SIGN TUREOFP RENT
ORGUARDIAN,
IF
APPLICANT
IS
AMINOR) Printed
Full
Name) HomeAddress)
SIGNATURE
OF
WITNESS
Printed
Full
Name HavingreviewedtheaboveAgreementandGeneral
Release
forspiritualassistance.including,butnotlimited
t
theIntrospectionRundown.theChurch,inrelianceupon,andconditionedupon.thetruthfulpromises.representationsandagreementsmadetherein.onthis
day
_
2 _
acceptsforparticipationinspiritualassistanceinthefuture
as
needed.
CHURCHOF
SCIENTOLOGY
_
By
its:_ Title
SIGNATURE
_