Private Membership Agreement for Lilly Fields
Holistic Health Educators
(A Private Membership Association)
MEMBERSHIP CONTRACT
Member Name:
First Name:_______________________ Last Name: ________________________
I, (name stated above) upon execution of this agreement and payment of the private membership
fee shown below, do hereby apply for membership in HOLISTIC HEALTH EDUCATORS, a private
membership organization. With the signing of this membership agreement I accept the offer made to
become a member of HOLISTIC HEALTH EDUCATORS and have read and agree with the Declaration
of Purpose from Article I of the HOLISTIC HEALTH EDUCATORS Articles of Association.
MEMORANDUM OF UNDERSTANDING
I understand that the fellow members of the Association that provide services and care, do so in the
capacity of a fellow member and not in the capacity as a licensed health care provider. I further
understand that within the association no doctor-patient relationship exists but only a contract
member-member Association relationship. In addition, I have freely chosen to change my legal
status as a public patient, customer, or client, to a private member of the Association. I further
understand that it is entirely my own responsibility to consider the advice and recommendations
offered to me by my fellow members and to educate myself as to the efficacy, risks, and desirability
of same and the acceptance of the offered or recommended diagnosis, therapy, treatment and care is
my own carefully considered decision. Any request by me to a fellow member to assist me or provide
me with the aforementioned diagnosis, therapy, treatment and care is my own free decision in an
exercise of my rights and made by me for my benefit, and I agree to hold the Trustee(s), staff and
other worker members and the Association harmless from any unintentional liability for the results of
such care, except for harm that results from instances of a clear and present danger of substantive
evil as determined by the Association, as stated and defined by the United States Supreme Court.
The members have chosen Karen Urbanek as the person best qualified to perform and/or provide
certain services to members of the association, and to identify and select other highly qualified
members to perform additional member services. In addition, I understand that, since the
Association is protected by the First and FourteenthAmendments to the U.S. Constitution, it is outside
the jurisdiction and authority of Federal and State Agencies and Authorities concerning any and all
complaints or grievances against the Association, any Trustee(s), members or other staff persons. All
rights of complaints or grievances will be settled by an Association Committee and will be waived by
the member for the benefit of the Association and its members.
If located outside of the United States, I also understand that the Association is created and
protected under the International Covenant on Civil and Political Rights, as ratified by the United
Nations General Assembly, pursuant to (among others) Part III, Articles 21 & 22 et. seq. regarding
the Right of Peaceful Assembly and Freedom of Association. Because the privacy and security of
membership records maintained within the Association which have been held to be inviolate by the
U.S. Supreme Court, the undersigned member waives HIPAA privacy rights and complaint process.
Any medical or healthcare records kept by the association will be strictly protected and only released
upon written request of the member. I agree that violation of any waivers in this membership
contract will result in a no contest legal proceeding against me. In addition, the Association does not
participate in any medical insurance plans or collections on behalf of the member but will provide a
suitable invoice for the member to pursue reimbursement by his/her insurance company, if
applicable. I agree to join the Association, a private membership association under common law,
whose members seek to help each other achieve better health and live longer with good quality of
life. I understand that the doctors, nurses, and other providers who are fellow members of the
Association are offering me advice, services, and benefits that do not necessarily conform to
conventional medical care. I do not expect these benefits to include on-call coverage, hospital care,
or the usual and customary care provided by most physicians. I will receive such primary and
specialist care elsewhere. I fully understand that the benefits I receive from the Association might or
might not be covered by my health insurance and not at all by Medicare.As a member, I accept the
goals of helping my body function better and choosing techniques that are both very safe and have a
reasonably good chance to succeed, realizing that no diagnostic technique or treatment is foolproof.
If I choose to forgo drugs, surgery, or radiation that has been recommended to me by others, I fully
accept the risk that I might suffer serious consequences from that choice. Other aspects of informed
consent will take place in my discussions with the providers and my fellow members of the
Association. My activities within the Association are a private matter that I refuse to share with the
State Medical Board, the FDA, FTC, Medicare, Medicaid, or my own insurance company without my
expressed specific permission. All records and documents remain as property of the Association, even
if I receive a copy of them. I fully agree not to file a malpractice lawsuit against a fellow member of
the Association unless that member has exposed me to a clear and present danger of substantive
evil. I acknowledge that the members of the Association do not carry malpractice insurance. I agree
to and acknowledge that no member, including myself, will intentionally cause any other member of
the association harm be it physical, spiritual, emotional or financial. I enter into this agreement of my
own free will or on behalf of my dependent without any pressure or promise of cure. I affirm that I do
not represent any State or Federal agency whose purpose is to regulate or approve any products. I
have read and understood this document, and my questions have been answered fully and to my
satisfaction. I understand that I can withdraw from this agreement and terminate my membership in
this association at any time. Upon termination of their agreement, I understand and agree that I will
immediately lose my right to view or participate in any programs offered by Holistic Health
Educators, and if applicable, any of its affiliates that require private membership. I agree to notify
Holistic Health Educators, in writing, upon my termination of this agreement. These pages and Article
I of the Articles of Association of the Association consist of the entire agreement for my membership
in the Association and they supersede any previous agreement.
ARTICLE I of the ARTICLES OF ASSOCIATION
Declaration of Purpose
1. This Association of members hereby declares that our main objective is to maintain and improve
the civil rights, constitutional guarantees, and political freedom of every member and citizen of the
United States of America, through the exercise of our constitutional rights. This objective also
pertains to all law-abiding citizens of other countries around the world whose constitutional provisions
embrace similar rights and freedoms as those in our United States of America.
2. As members, we affirm our belief in the Constitution of the United States of America. We believe
that the First Amendment of the Constitution guarantees our members the rights of free speech,
petition, assembly, and the right to gather together for the lawful purpose of advising and helping
one another in asserting our rights under the Federal and State Constitutions and Statutes. We strive
to maintain and improve the civil rights, constitutional guarantees, freedom of choice in health care
and political freedom of every member and citizen of the United States of America and abroad.
IT IS HEREBY Declared that we are exercising our right of “freedom of association” as guaranteed by
the 1st and 14th Amendments of the United States Constitution and equivalent provisions of the
various State Constitutions. This means that our association activities are restricted to the private
domain only.
3. We declare the basic right of all of our members to select spokespersons from our number who
could be expected to give counsel and advice concerning the need for physical and mental health
care assistance and to select from our number those members most qualified to assist and facilitate
the delivery of education, therapy, treatment and care to other members.
4.We proclaim the freedom to choose and perform for ourselves the types of therapies and treatment
modalities that we think best for diagnosing, treating and preventing illness and disease of our minds
and bodies and for achieving and maintaining optimum wellness. We proclaim and reserve the right
to provide medical and health options that include but are not limited to cutting edge treatment
modalities and therapies practiced or used by any types of healers, therapists or practitioners the
world over whether traditional or nontraditional, conventional or unconventional.
5.The Association specializes in health and wellness education, explaining therapy options, human
body functionality, and various other wellness techniques for optimization of health and well-being. It
is each member’s responsibility to practice due diligence in research and consult with the professional
healthcare provider of their choice, before moving forward with any therapy or lifestyle change, and
no member of the association will be held responsible for another member’s health outcome or level
of understanding.
6. The Association will recognize any person (irrespective of race, color, or religion) who is in
accordance with these principles and policies as a member, and will provide a medium through which
its individual members may associate for actuating and bringing to fruition the purposes heretofore
declared.
Acknowledgement
1. I understand that the membership fee entitles me to receive those benefits declared by the
Trustee(s) to be “general benefits” free of further charge. I agree to pay as levied those benefits that
I receive that are declared by the Trustees to be “special assessments OR SERVICES”, per Fee
Schedule.
2. I am aware that the cost of $10.00 (included in my product) is consideration for my one-time
lifetime membership contract, said term beginning with the date of the signing of this contract, and
by these presents do hereby certify, attest and warrant that I have carefully read the above and
foregoing HOLISTIC HEALTH EDUCATORS Contractual Application for Membership and I fully
understand and agree with same.
IN WITNESS WHEREOF I set my hand this date:
Date: __________________
Applicant Name:
First Name:_______________________ Last Name: _______________________
(if applicant is a minor, Name of Legal Guardian:
First Name:_______________________ Last Name: ________________________
Signature: _________________________________________________________
Email: _____________________________________________________________
Address: ___________________________________________________________
Phone Number: _____________________________________________________
(A Private Membership Association)
MEMBERSHIP CONTRACT
Member Name:
First Name:_______________________ Last Name: ________________________
I, (name stated above) upon execution of this agreement and payment of the private membership
fee shown below, do hereby apply for membership in HOLISTIC HEALTH EDUCATORS, a private
membership organization. With the signing of this membership agreement I accept the offer made to
become a member of HOLISTIC HEALTH EDUCATORS and have read and agree with the Declaration
of Purpose from Article I of the HOLISTIC HEALTH EDUCATORS Articles of Association.
MEMORANDUM OF UNDERSTANDING
I understand that the fellow members of the Association that provide services and care, do so in the
capacity of a fellow member and not in the capacity as a licensed health care provider. I further
understand that within the association no doctor-patient relationship exists but only a contract
member-member Association relationship. In addition, I have freely chosen to change my legal
status as a public patient, customer, or client, to a private member of the Association. I further
understand that it is entirely my own responsibility to consider the advice and recommendations
offered to me by my fellow members and to educate myself as to the efficacy, risks, and desirability
of same and the acceptance of the offered or recommended diagnosis, therapy, treatment and care is
my own carefully considered decision. Any request by me to a fellow member to assist me or provide
me with the aforementioned diagnosis, therapy, treatment and care is my own free decision in an
exercise of my rights and made by me for my benefit, and I agree to hold the Trustee(s), staff and
other worker members and the Association harmless from any unintentional liability for the results of
such care, except for harm that results from instances of a clear and present danger of substantive
evil as determined by the Association, as stated and defined by the United States Supreme Court.
The members have chosen Karen Urbanek as the person best qualified to perform and/or provide
certain services to members of the association, and to identify and select other highly qualified
members to perform additional member services. In addition, I understand that, since the
Association is protected by the First and FourteenthAmendments to the U.S. Constitution, it is outside
the jurisdiction and authority of Federal and State Agencies and Authorities concerning any and all
complaints or grievances against the Association, any Trustee(s), members or other staff persons. All
rights of complaints or grievances will be settled by an Association Committee and will be waived by
the member for the benefit of the Association and its members.
If located outside of the United States, I also understand that the Association is created and
protected under the International Covenant on Civil and Political Rights, as ratified by the United
Nations General Assembly, pursuant to (among others) Part III, Articles 21 & 22 et. seq. regarding
the Right of Peaceful Assembly and Freedom of Association. Because the privacy and security of
membership records maintained within the Association which have been held to be inviolate by the
U.S. Supreme Court, the undersigned member waives HIPAA privacy rights and complaint process.
Any medical or healthcare records kept by the association will be strictly protected and only released
upon written request of the member. I agree that violation of any waivers in this membership
contract will result in a no contest legal proceeding against me. In addition, the Association does not
participate in any medical insurance plans or collections on behalf of the member but will provide a
suitable invoice for the member to pursue reimbursement by his/her insurance company, if
applicable. I agree to join the Association, a private membership association under common law,
whose members seek to help each other achieve better health and live longer with good quality of
life. I understand that the doctors, nurses, and other providers who are fellow members of the
Association are offering me advice, services, and benefits that do not necessarily conform to
conventional medical care. I do not expect these benefits to include on-call coverage, hospital care,
or the usual and customary care provided by most physicians. I will receive such primary and
specialist care elsewhere. I fully understand that the benefits I receive from the Association might or
might not be covered by my health insurance and not at all by Medicare.As a member, I accept the
goals of helping my body function better and choosing techniques that are both very safe and have a
reasonably good chance to succeed, realizing that no diagnostic technique or treatment is foolproof.
If I choose to forgo drugs, surgery, or radiation that has been recommended to me by others, I fully
accept the risk that I might suffer serious consequences from that choice. Other aspects of informed
consent will take place in my discussions with the providers and my fellow members of the
Association. My activities within the Association are a private matter that I refuse to share with the
State Medical Board, the FDA, FTC, Medicare, Medicaid, or my own insurance company without my
expressed specific permission. All records and documents remain as property of the Association, even
if I receive a copy of them. I fully agree not to file a malpractice lawsuit against a fellow member of
the Association unless that member has exposed me to a clear and present danger of substantive
evil. I acknowledge that the members of the Association do not carry malpractice insurance. I agree
to and acknowledge that no member, including myself, will intentionally cause any other member of
the association harm be it physical, spiritual, emotional or financial. I enter into this agreement of my
own free will or on behalf of my dependent without any pressure or promise of cure. I affirm that I do
not represent any State or Federal agency whose purpose is to regulate or approve any products. I
have read and understood this document, and my questions have been answered fully and to my
satisfaction. I understand that I can withdraw from this agreement and terminate my membership in
this association at any time. Upon termination of their agreement, I understand and agree that I will
immediately lose my right to view or participate in any programs offered by Holistic Health
Educators, and if applicable, any of its affiliates that require private membership. I agree to notify
Holistic Health Educators, in writing, upon my termination of this agreement. These pages and Article
I of the Articles of Association of the Association consist of the entire agreement for my membership
in the Association and they supersede any previous agreement.
ARTICLE I of the ARTICLES OF ASSOCIATION
Declaration of Purpose
1. This Association of members hereby declares that our main objective is to maintain and improve
the civil rights, constitutional guarantees, and political freedom of every member and citizen of the
United States of America, through the exercise of our constitutional rights. This objective also
pertains to all law-abiding citizens of other countries around the world whose constitutional provisions
embrace similar rights and freedoms as those in our United States of America.
2. As members, we affirm our belief in the Constitution of the United States of America. We believe
that the First Amendment of the Constitution guarantees our members the rights of free speech,
petition, assembly, and the right to gather together for the lawful purpose of advising and helping
one another in asserting our rights under the Federal and State Constitutions and Statutes. We strive
to maintain and improve the civil rights, constitutional guarantees, freedom of choice in health care
and political freedom of every member and citizen of the United States of America and abroad.
IT IS HEREBY Declared that we are exercising our right of “freedom of association” as guaranteed by
the 1st and 14th Amendments of the United States Constitution and equivalent provisions of the
various State Constitutions. This means that our association activities are restricted to the private
domain only.
3. We declare the basic right of all of our members to select spokespersons from our number who
could be expected to give counsel and advice concerning the need for physical and mental health
care assistance and to select from our number those members most qualified to assist and facilitate
the delivery of education, therapy, treatment and care to other members.
4.We proclaim the freedom to choose and perform for ourselves the types of therapies and treatment
modalities that we think best for diagnosing, treating and preventing illness and disease of our minds
and bodies and for achieving and maintaining optimum wellness. We proclaim and reserve the right
to provide medical and health options that include but are not limited to cutting edge treatment
modalities and therapies practiced or used by any types of healers, therapists or practitioners the
world over whether traditional or nontraditional, conventional or unconventional.
5.The Association specializes in health and wellness education, explaining therapy options, human
body functionality, and various other wellness techniques for optimization of health and well-being. It
is each member’s responsibility to practice due diligence in research and consult with the professional
healthcare provider of their choice, before moving forward with any therapy or lifestyle change, and
no member of the association will be held responsible for another member’s health outcome or level
of understanding.
6. The Association will recognize any person (irrespective of race, color, or religion) who is in
accordance with these principles and policies as a member, and will provide a medium through which
its individual members may associate for actuating and bringing to fruition the purposes heretofore
declared.
Acknowledgement
1. I understand that the membership fee entitles me to receive those benefits declared by the
Trustee(s) to be “general benefits” free of further charge. I agree to pay as levied those benefits that
I receive that are declared by the Trustees to be “special assessments OR SERVICES”, per Fee
Schedule.
2. I am aware that the cost of $10.00 (included in my product) is consideration for my one-time
lifetime membership contract, said term beginning with the date of the signing of this contract, and
by these presents do hereby certify, attest and warrant that I have carefully read the above and
foregoing HOLISTIC HEALTH EDUCATORS Contractual Application for Membership and I fully
understand and agree with same.
IN WITNESS WHEREOF I set my hand this date:
Date: __________________
Applicant Name:
First Name:_______________________ Last Name: _______________________
(if applicant is a minor, Name of Legal Guardian:
First Name:_______________________ Last Name: ________________________
Signature: _________________________________________________________
Email: _____________________________________________________________
Address: ___________________________________________________________
Phone Number: _____________________________________________________