Consensual Sexual Acts & Confidentiality Agreementв„ў
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READ CAREFULLY. By signing this Agreement you may be significantly waiving or limiting important legal or personal rights.
I, _____________________________________ (the “Consenting Party”), declare that I am over the legal age of sexual consent and over the legal
age of consent to enter into this Agreement, in this State of ________________________, of sound and disposing mind and memory, not mentally
disabled, and not acting under duress, force, violence, menace, fear of immediate and unlawful bodily injury on my person or another, fraud or deceit,
misrepresentation, mistake, undue influence, coercion (some intimate powers of romantic persuasion are acceptable), mixed emotions or feelings, or
under heat of moment. I declare that I am at this time not under the influence of alcohol, drugs, medication, and/or any external substance that may
impair my judgment or ability to make informed decisions.
My Partner, _____________________________________ (“My Partner”), and I have agreed to spend an intimate time together and to satisfy each
other’s sexual desires. This intimate time together is entirely voluntary, welcome and consensual. I acknowledge, accept and agree that I am entering
into this Agreement as a declaration of my intent to participate in consensual sexual acts with My Partner. I agree not to falsely claim to be the victim
of sexual harassment, sexual assault, and/or rape for participating in consensual sexual acts with My Partner.
CONFIDENTIALITY: Both parties agree to keep the entire sexual activities completely confidential, except in case of accusation of rape or sexual
assault and/or civil claims.
I AGREE TO PARTICIPATE IN THE FOLLOWING CONSENSUAL SEXUAL ACTS:
INITIAL THE SEXUAL ACTS YOU WISH TO PARTICIPATE
(A)
(B)
(C)
(D)
Physical contact (e.g. touching, kissing, fondling, receiving and inflicting sexual pain, use of sex aids and toys) _________
Sexual penetration of Vagina _________ Anus _________ Both _________ with fingers, sex aids and toys, or foreign objects
Oral sex _________ Anal-oral sex _________ Both _________ [Ejaculation in mouth _________ Yes _________ No]
Sexual intercourse with an FDA approved condom at all times _________ without a condom _________ [Ejaculation in vagina _________ Yes _________ No]
*[I understand that by engaging in sexual intercourse without a condom, I am representing to My Partner that I am using
birth control as prescribed and directed, or I am physically or medically incapable of becoming pregnant.]
(E) Anal intercourse with an FDA approved condom at all times _________ without a condom _________ [Ejaculation in anus _________ Yes _________ No]
(F) Special instructions: __________________________________________________________________________________________________________________
WITHDRAWAL OF CONSENT INSTRUCTION: I understand that I have the legal right to withdraw consent at any time; however, I agree
to act in “Good Faith” and not change my mind during the course of the consensual sexual acts in which I participate, or during the course of sexual
penetration which may be difficult for My Partner to control the urge to orgasm. If I do choose to withdraw consent in “Good Faith”, it is understood
that when I unambiguously and audibly communicate the words “TIME-OUT”, My Partner agrees to STOP AND DESIST WITHIN THREE (3)
SECONDS. If I suffer from a speech disability or disorder, it is understood that my hands in no way shall be constrained, so that when I
unambiguously communicate the time-out gesture, “THE LETTER “T” MADE WITH BOTH HANDS”, My Partner agrees to STOP AND
DESIST WITHIN THREE (3) SECONDS. To prevent misunderstandings, I will not use the words “NO”, “STOP”, or use ambiguous sexual
communication which is commonly used playfully, teasingly, or frivolously as a desire for sexual gratification, and is not always taken seriously to
convey unwillingness to further participation.
________ _________ BOTH PARTIES INITIALS
ASSUMPTION OF RISK AND INDEMNITY: Both parties to the best of his/her knowledge have disclosed to the other party any and all material
facts known with respect to his/her health, participation in prior sexual activities, and any and all known Sexually Transmitted Diseases (STDs)
and/or HIV/AIDS infection that he/she may have contracted from prior experiences. My Partner shall not be imputed with constructive knowledge
with respect to any health conditions or risks. I know and understand sexual activity is not without RISKS AND DANGERS of serious bodily
injury, including transmission or contraction of Sexually Transmitted Diseases (STDs), HIV/AIDS infection, and/or death. These risks and
dangers may be caused by my own actions or inactions, the actions or inactions of My Partner, the actions or inactions of others
participating in the sexual activities, the condition in which these sexual activities take place, risks associated with a partner involved with
multiple partner sexual activities, or there may be other risks either not actually known, not disclosed, or not readily foreseeable at this time;
and I VOLUNTARILY AND FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR ANY AND ALL
INJURIES, including but not limited to, condom failure, birth control failure, or any misrepresentations I have made to My Partner with
respect to birth control or fertility. I fully and unconditionally release, indemnify, defend and hold harmless, My Partner and his/her legal
representatives, from any and all liability, claims, remuneration claims, losses, damages, costs, expenses, and attorneys' fees.
SEVERABILITY, SURVIVAL, AND INTERPRETATION: If any provision, or portion of a provision, of this Agreement is held in whole or in
part to be illegal, unenforceable, or invalid for any reason, the remainder of that provision, or portion, and of the entire Agreement will be severable
and remain in full force and effect. The language in this Agreement shall be interpreted as to its fair meaning and not strictly for or against any party.
Any ambiguity regarding the issue of consent shall be resolved in favor of consent. Caption headings are for convenience purposes only and are not
to be used to interpret or define the provisions of this Agreement.
MERGER, INCORPORATION, AND MODIFICATION: This Agreement sets forth the entire Agreement and understanding between the parties
relating to the subject matter herein and supersedes all prior discussions between the parties. This Agreement may not be modified except by a
separate writing and signed by both parties.
BOTH PARTIES AGREE TO AND UNDERSTAND THE CONTENTS, LEGAL EFFECTS AND CONSEQUENCES OF THIS AGREEMENT.
IT IS AGREED AND ACKNOWLEDGED THAT THIS AGREEMENT IS VALID FOR SEXUAL ACTIVITIES ENTERED INTO ON
THE CALENDAR DATE BELOW. CONSENTING PARTY DECLARES IN ADVANCE THE CAPACITY AND WILLINGNESS TO
SUBSEQUENT PARTICIPATION (i.e. MULTIPLE SEXUAL ACTS OR RE-PENETRATION AFTER INTERMISSION) ON THE SAME
CALENDAR DATE BELOW. FUTURE SEXUAL ACTS BETWEEN BOTH PARTIES ON A DIFFERENT CALENDAR DATE OR
AFTER CONSENT HAS BEEN WITHDRAWN MUST BE SIGNED BY SEPARATE AGREEMENT. THIS AGREEMENT IS EFFECTIVE
IMMEDIATELY UPON THE SIGNATURE OF BOTH PARTIES AND WILL CONTINUE WITHOUT LIMITATION UNTIL CONSENT IS
WITHDRAWN BY EITHER PARTY TO THIS AGREEMENT.
Signed “Consenting Party”: _______________________________________ Date: _____________________
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Signed “My Partner”: ____________________________________________ Time: _______________ AM / PM (circle)
