Name *

First Name

Last Name

Are you currently attending a church? *

Yes

No

Are you currently in a church leadership position? *

Yes

No

Does the subject of deconstruction scare you? *

Yes

No

What Numa subscription groups are you currently part of? *

Numa+

LYL

OCG

DSMG

Sparkle

NSD

None of the above

Please read the liability waiver below:

This Numa group is a service that provides groups coaching to specific individuals and/or groups. The client is aware that coaching is in no way to be construed or substituted as psychological counseling or any other type of therapy or medical advice. The client understands and acknowledges the coach will not be liable legally or otherwise, for the actions the client may or may not undertake as a result of the coaching sessions. No assumption of responsibility is made, or given, and the client requesting such advice agrees not to hold Mike Maeshiro or affiliate of Numa groups responsible or liable in any form or fashion, for such actions taken of their own accord. The method and process by which this advice and direction are given in no manner whatsoever, written or verbal, constitutes an agreement or liability on the part of the provider and is acknowledged to be different in many ways than clinical and medical counseling. You (the client) agree that using any of these Numa group services are entirely at your own risk. Life coaching services are provided "as is", without warranty of any kind, either expressed or implied, including without limitation any warranty for information services, coaching, uninterrupted access, or products and services provided through or in connection with the service. This service is requested at the client's own choice and with inherent singular responsibility. Any actions or lack of actions taken by the client of such advice is done so solely by choice and responsibility of the client and is neither the responsibility nor liability of Mike Maeshiro or affiliate of Numa groups. The client takes full responsibility in the decisions they make after being coached as well as the consequences. The client enters into coaching with full understanding that they are responsible for creating their own results. Periodically I or my team, may provide links to other web sites or written print material which may be of value, interest and convenience to you. This does not constitute an endorsement of material at those sites or any associated organization product or service. It is the responsibility of the user to make their own informed decision about the accuracy of the information at those sites and print material including their privacy policies. In no event shall Mike Maeshiro or affiliate of Numa groups be liable for any incident or consequential damages resulting from use of the material. With hope and enthusiasm, Mike Maeshiro. Ashes is a monthly subscription service that will automatically charge the client’s bank account every month. Numa does not offer refunds. I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY CHECKING THE BOX TO ACKNOWLEDGE IT, AND HAVE ACKNOWLEDGED IT FREELY AND VOLUNTARILY WITHOUT INDUCEMENT, ASSURANCE OR GUARANTEE BEING MADE TO ME AND INTEND MY ACKNOWLEDGMENT TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY, INCLUDING ANY NEGLIGENCE OF THE ORGANIZATION NAMED BELOW TO THE GREATEST EXTENT ALLOWED BY LAW.

I acknowledge that I have read and agree to the liability release form above