Scholarship Placenta Encapsulation Contract Complete this form to hire Michelle Rickard of Puget Sound Placenta as your encapsulation specialist. Your Name* First Last Email* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I qualify for the scholarship in the following way(s):* I am under the age of 21. I will be a single parent. I am currently approved for WIC or food stamps. Both my partner and I are full time students. My husband/partner is active duty military or is a disabled veteran. You only need to one option to qualify.Baby's Birth or Due Date* Birth Place*Names of people that you designate to pick up the finished capsules.*Are you allergic to latex?*NoYes(Please List)Do you have any food or environmental allergies?*NoYesIf Yes, Please ListDo you or your partner have any infectious diseases?*NoYesSuch as HIV, AIDS, Hepatitis, Herpes, etc.If Yes, Please ListEncapsulation MethodSimply Dehydrated: sliced raw and dehydrated at 160 degrees. Raw Foods: sliced raw and dehydrated at 115 degrees. Simply Steamed & Dehydrated: steamed, sliced and dehydrated at 125 degrees. For more information on methods click hereI choose this method of preparation for my placenta*Simply DehydratedRaw FoodsSimply Steamed & DehydratedHalf & Half ($25 fee, write 2 methods below)Placenta Enhancements for SteamingAs a default your capsules will contain nothing but pure placenta. You may decide to enhance your placenta preparation with the use of certain foods or herbs. An enhancement added during steaming will not be dried and powdered into the finished capsules but the placenta will be infused with it by the steaming process. By checking an item here you acknowledge that you have researched the enhancements and assume responsibility for consuming them.I would like to add the following enhancements to my placenta during steaming: None Lemon Jalepeno Ginger Garlic Frankincense Myrrh Alfalfa Fenugreek Capsule TypeThe capsule types I always have in stock are size 0: clear vegetarian or purple, berry flavored gelatin. By special request and with advanced notice you can choose one of the following flavors: lime, strawberry, mint, coffee, bubblegum or grape. Other sizes are also available by special request.I choose this type of capsule:*Size 0 clear vegetarianSize 0 berry gelatinAdd On Services Email me pictures of my placenta. Email me a report of my placenta. Dried cord keepsake (free, note shape below). Blood & Paper Imprints ($25 fee) Placenta Tincture ($30 fee) Twin Placentas ($25 fee) Cord keepsake shapes: heart, circle, spiral, infinity loop.Photo ReleaseI take photos of your placenta for record keeping purposes. These photos are available to you at any time. With your permission I may use these photos for marketing, advertising, education, peer review or promotional purposes in print or online. Identifying information will not be shared under any circumstances.Do you give permission for photos of your placenta to be used as described above?*Yes. You may use the photos.No. Do not use the photos.Client Responsibilities Talk to your care provider during a prenatal visit about your intended birth place’s policies in regards to releasing the placenta. Sign any forms required and have them placed in your file. If you are birthing in a hospital: remind your care providers upon arrival that you plan to take your placenta and remind them again during pushing. Put your placenta into a covered container, secured biohazard bag or double ziplock bag. The container must be labeled with your name before someone brings it to me. It can remain at room temperature for 3-4 hours following the birth. Refrigerate or put it on ice as soon as reasonably possible. Improperly handled placentas are susceptible to spoilage. Do not let the placenta out of your sight. I will not encapsulate placentas that are sent to a hospital's pathology lab. Call or text message Emily at (206) 552-0484 after the birth to arrange a time to drop off the placenta. Please call between 7am and 10pm. Anyone may drop off the placenta as long as it is properly labelled. Only persons designated on this contract will be allowed to pick up the finished capsules. The drop off & pick up location is 13729 Cascadian Way, Everett, WA 98208 or 4733 Ballard Ave, Seattle (only M-F from 7a-3p). If you are not able to contact me within 4 days of the birth, freeze the placenta until you are ready to drop it off. Encapsulation takes 24-48 hours for a refrigerated placenta. A frozen placenta may take additional time so that it can be safely thawed.Limitations and Disclaimer (Scroll to Review)I understand and acknowledge that in accordance to Washington law, choosing to encapsulate my placenta is not intended to prevent or treat any physical or mental diseases, ailments or symptoms and that I am choosing to consume my placenta for my own personal beliefs, whether it be spiritual or cultural. I also acknowledge that there are no statewide regulations preventing me from obtaining and encapsulating my placenta in my home. I acknowledge that Emily Fontes has provided me with concrete information about both the benefits and risks of placenta encapsulation, and have read all included documents. I understand that my placenta will be handled and encapsulated according to OSHA and Washington Food Safety and Handling standards, and will be cleaned, cooked, dehydrated and put into pill form in a sanitary and sterile work space. Upon receiving my placenta capsules from Emily Fontes, I waive any and all rights to hold the specialist responsible for any undesired effect of consuming the capsules. If my placenta is not encapsulated in my own home, I put full trust and acknowledgement that it is being handled in a sanitary and safe environment. I have disclosed to Emily Fontes my STD status. I understand that upon receiving the pills, Emily Fontes is no longer liable, including but not limited to any other person(s) ingesting my own placenta capsules. I do not hold Emily Fontes responsible or liable for any transport mishap that is beyond her control (ex. car accident or detainment).Cancellation Policy In the event you receive medical treatment that renders the placenta unusable, please email me. I can provide suggestions on other ways you can balance postpartum mood or increase milk supply. If you change your mind about encapsulation and want to cancel after signing this contract, please email me as a courtesy so that I can take you off my calendar. Payment in full is due when the placenta is dropped off to me. If you choose to cancel after dropping off the placenta but before I begin preparing it: a refund will be given. You may pick up your placenta or instruct me to dispose of it. If you choose to cancel once I have begun preparing the placenta: no refund will be given even if you choose not to take delivery of the finished capsules. I agree to the preceding Client Responsibilities, Limitations and Disclaimer and Cancellation Policy by signing below:*Draw your signature into the box. It's okay if it's a bit messier than normal.