Church of Scientology
Flag Service Organization
(hereinafter referred to as "the Church")
Agreement and General Release
Regarding Spiritual Assistance

1. I, ___________________________________, recognize, acknowledge and agree that I am exclusively responsible for my present and future condition in life and for the choices and decisions I make affecting my life. With that in mind, and solely of my own volition and in the independent exercise of my own free will, I am voluntarily signing and submitting to CHURCH OF SCIENTOLOGY ___________________________________ (hereinafter the "Church") this AGREEMENT AND GENERAL RELEASE REGARDING SPIRITUAL ASSISTANCE (hereinafter this "Contract") so that, upon its acceptance by the Church, I may participate in Scientology Religious Services and spiritual assistance under the terms, conditions, covenants, waivers and releases I agree to by signing this contract, and by doing so, I specifically acknowledge and reaffirm all other waivers, releases and agreements I have signed with any Church of Scientology.

2. This contract is my statement of my personal understanding concerning Scientology religious tenets and my statements reflecting my own beliefs and desires. By signing this Contract, I recognize, acknowledge and agree that:

a. Scientology is a religion, the Church is a church of the Scientology religion and all the services and activities of the Scientology religion are exclusively religious in nature.

b. Scientology is unalterably opposed, as a matter of religious belief, to the practice of psychiatry, and espouses as a religious belief that the study of the mind and the healing of mentally caused ills should not be alienated from religion or condoned in nonreligious fields. I am in full agreement with this religious belief. I do not believe in or subscribe to psychiatric labels for individuals It is my strongly held religious belief that all mental problems are spiritual in nature and that there is no such thing as a mentally incompetent person-- only those suffering from spiritual upset of one kind or another dramatized by an individual. I reject all psychiatric labels and intend for this Contract to clearly memorialize my desire to be helped exclusively through religious, spiritual means and not through any form of psychiatric treatment, specifically including involuntary commitment based on so-called lack of competence. Under no circumstances, at any time, do I wish to be denied my right to care from members of my religion to the exclusion of psychiatric care or psychiatric directed care, regardless of what any psychiatrist, medical person, designated member of the state or family member may assert supposedly on my behalf. If circumstances should ever arise in which government, medical or psychiatric officials or personnel or family members or friends attempt to compel or coerce or commit me for psychiatric evaluation, treatment or hospitalization, I fully desire and expect that the Church or Scientologists will intercede on my behalf to oppose such efforts and/or extricate me from that predicament so my spiritual needs may be addressed in accordance with the tenets of the Scientology religion.

c. As I so strongly disagree, as a matter of religious principle, with the use of psychiatric treatment for anyone, including myself, I reject the usage of psychiatric labels and I believe in assisting individuals through religious and spiritual means. Therefore, I am hereby specifying that should I get into a situation in the future, unlikely as it is, where others may think that I need psychiatric treatment of any kind, that I instead desire to receive Scientology spiritual assistance and that it can include, but is not limited to, the Introspection Rundown. Further, I realize that in the future it may consequently be suggested by a senior Scientology minister, should the need arise, that I receive such spiritual assistance, and again, I want to make it clear that under such circumstances I desire to receive Scientology Spiritual Assistance, which may include, but not be limited to, the Introspection Rundown.

d. The Scientology religion teaches that the spirit can be saved and that the spirit alone may save or heal the body, and the Introspection Rundown is intended to save the spirit. I understand that the Introspection Rundown is an intensive, rigorous Religious Service that includes being isolated from all sources of potential spiritual upset, including but not limited to family members, friends or others with whom I might normally interact. As part of the Introspection Rundown, I specifically consent to Church members being with me 24 hours a day at the direction of my Case Supervisor, in accordance with the tenets and custom of the Scientology religion. The Case Supervisor will determine the time period in which I will remain isolated, according to the beliefs and practices of the Scientology religion. I further specifically acknowledge that the duration of any such isolation is uncertain, determined only by my spiritual condition, but that such duration will be completely at the discretion of the Case Supervisor. I also specifically consent to the presence of Church members around the clock for whatever length of time is necessary to perform the Introspection Rundown's processes and to achieve the spiritual results of the Introspection Rundown. I understand, acknowledge and agree that the Introspection Rundown addresses only the individual's spiritual needs and I freely consent, without reservation, and without condition or limitation, to Church members conducting the Introspection Rundown, and that I accept and assume all known and unknown risks of injury, loss, or damage resulting from my decision to participate in the Introspection Rundown and specifically absolve all persons and entities from all liabilities of any kind, without limitation, associated with my participation or their participation in my Introspection Rundown.

I HAVE CAREFULLY READ THIS CONTRACT AND FULLY UNDERSTAND ITS CONTENTS AND CONSEQUENCES. I ALSO UNDERSTAND THAT I AM NOT ELIGIBLE FOR SPIRITUAL ASSISTANCE UNLESS I SIGN THIS CONTRACT. WHILE IT IS UNLIKELY THAT I WILL EVER BE IN A CONDITION WHERE PSYCHIATRIC INTERVENTION MAY BE DEEMED AN OPTION, I HEREWITH REAFFIRM THAT IN SUCH AN EVENT I WISH TO RECEIVE ONLY SCIENTOLOGY SPIRITUAL ASSISTANCE, INCLUDING, BUT NOT LIMITED TO THE INTROSPECTION RUNDOWN, AND THAT THIS CHOICE IS AN INDEPENDENT EXERCISE OF MY OWN FREE WILL. I FULLY UNDERSTAND THAT BY SIGNING BELOW, I AM FOREVER GIVING UP MY RIGHT TO SUE THE CHURCH, ITS STAFF AND ANY OF THE RELEASEES NAMED IN THE GENERAL RELEASE I SIGNED, FOR ANY INJURY OR DAMAGE SUFFERED IN ANY WAY CONNECTED WITH SCIENTOLOGY RELIGIOUS SERVICES OR SPIRITUAL ASSISTANCE.

I sign this Agreement and General Release Regarding Spiritual Assistance on this __ day of _________, 20__, intending to be legally bound to it, and request that I be permitted to participate in spiritual assistance.

______________________________________________
(SIGNATURE OF APPLICANT}

______________________________________________
(Printed Full Name)

______________________________________________
(Home Address)

______________________________________________
(SIGNATURE OF PARENT OR GUARDIAN, IF APPLICANT IS A MINOR)

______________________________________________
(Printed Full Name)

______________________________________________
(Home Address)

______________________________________________

______________________________________________
(SIGNATURE OF WITNESS)

______________________________________________
(Printed Full Name)

Having reviewed the above Agreement and General Release for spiritual assistance, including, but not limited to the Introspection Rundown, the Church, in reliance upon, and conditioned upon, the truthful promises, representation and agreements made therein, on this ___ day of _______, 20__, accepts _________________ for participation in spiritual assistance in the future as needed.

CHURCH OF SCIENTOLOGY ____________________________________

By its: _____________________________________________
                                     (Title)

(SIGNATURE) _________________________________________________

 

 

© 2001 CSFSO all rights reserved. Flag Service Org Corporate symbol SCIENTOLOGY and INTROSPECTION RUNDOWN are trademarks & service marks owned by Religious Technology Center and are used with its permission SCIENTOLOGISTS is a collective membership mark designating members of the affiliated churches and missions of Scientology. Services relating to Scientology religious philisophy are delivered throughout the world exclusively by licensees of the Church of Scientology International with the permission of Religious Technology Center holder of the SCIENTOLOGY and DIANETICS trademarks. Printed in U S A