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Liability Waiver: Breakin' Bread

Beloved community, đź’›

Thank you so much for your interest in Breakin’ Bread - A Food & Grief series.
Before joining us at the Breakin’ Bread table, please take a moment to review and complete the following consent and liability form.

My Contact Info

Emergency Contact Info

Participation & Release of Liability

Breakin' Bread: Food + Grief series is intended for community support purposes and is not a substitute for professional healthcare, counseling, or crisis services. I understand that Mosaic PDX and its facilitators are not providing medical, psychiatric, or licensed therapeutic services. If I am experiencing acute distress, I understand that it is my responsibility to seek appropriate professional help. I understand that I am voluntarily participating in the Breakin' Bread event and can choose to not participate at any moment. To the fullest extent permitted by law, I release and hold harmless Mosaic PDX, its organizers, facilitators, volunteers, partners, and venue providers from all claims, arising from or related to my participation in the event.

Acknowledgement of Participation & Release of Liability

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B

Food Allergen Acknowledgement

I understand that food and beverages may be provided at the Breakin' Bread event, either by Mosaic PDX, volunteers, participants, or partner vendors. I acknowledge that while reasonable efforts may be made to accommodate allergens and to label ingredients when possible, Mosaic PDX cannot guarantee that food will be free from allergens or cross-contamination, including but not limited to nuts, dairy, gluten, soy, eggs, shellfish, or other allergens. I agree that I am solely responsible for:

-- Informing event organizers of any food allergies prior to consuming food. -- Asking questions about ingredients when needed. -- Deciding whether it is safe for me to eat or drink any items provided.

Acknowledgement of Food & Allergens

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B

Photo & Media Release

Out of respect and privacy of all participants, no photos, videos, or audio recordings will be taken during facilitated discussions, reflections, or other sensitive moments.

Photos or media may be captured during designated times (such as before the event begins, during the meal, or at the end with explicit permission).

I understand that I may opt out of being photographed at any time by notifying facilitators or photographers present. Mosaic PDX will make reasonable efforts to honor privacy requests but cannot guarantee removal of images publicly.

Photo & Media Release

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B

Code of Care & Conduct

This event may include group discussions, creative expression, movement, emotional reflection, and community-based activities centered around grief, healing, and personal experiences. I agree to participate respectfully, honor confidentiality within the group, and contribute to a space that is inclusive, supportive, and centered on BIPOC community care. I understand that Mosaic PDX reserves the right to remove participants whose behavior disrupts the safety or integrity of the space. Please view our Breakin' Bread Community Agreements here.

Acknowledgement for Code of Care & Conduct

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B

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