Waiver Form-- Yoga Therapy
SECTION I: PERSONAL INFORMATION
* Name:_________________________________________________________________________________________________________________
*Address: __________________________________________*City: ________________________________________*Zip Code: _______________
Primary Phone: ___________________________________________ (Cell and Home if applicable) *E-mail: _________________________________
*Emergency Contact Name: _________________________________________________ *Emergency Contact Phone: _______________________
(* denotes required fields)
Previous Yoga Experience? _____________________________________________________________________________________________________________
SECTION II: RISK ASSESSMENT (Indicate if you have any of the following health problems.)
Heart Disease YES NO
Shortness of Breath or Chest Pain YES NO Inhaler? YES NO (if “yes”, please bring inhaler to every class)
High Blood Pressure YES NO Levels: ____________________________
High Cholesterol Level YES NO
Significant Bone/Joint/Muscle Pain YES NO Location: ____________________________
Back Pain YES NO
Cigarette Smoking YES NO Levels: ____________________________
Abnormal Resting EKG YES NO
Diabetes YES NO Insulin Dependent? YES NO
Any other? Please explain: _____________________________________________________________________________________
Are you active? YES NO
Activity or Exercise: ___________________________________
Times per week: ___________
Minutes per session: ___________
Are you currently taking any medication(s)? YES NO Type: ____________________________________________
Are you pregnant or planning to become pregnant in the near future? YES NO
SECTION III: AGREEMENT
1. In consideration of participating in Yoga, I agree and acknowledge that I am fully aware that participation in the Activity involve risks and I accept all the risks of participating, even if the risks are created by the carelessness, negligence or gross negligence of a Released Party (as defined below) or anyone else.
2. “Claims” includes but is not limited to any and all liabilities, claims, demands, legal actions, rights of actions for damages, personal injury or death in connection with participation in this Yoga practice. “Released Party” Michelle Cormack
3. I agree and acknowledge that:
a. I am in proper physical condition to participate in Yoga, and am aware that participation could, in some circumstances, result in physical injury, serious physical injury or death.
b. I understand my physical limitations and am sufficiently self-aware to stop physical activity before I become ill or injured.
4. I accept full responsibility for any product or technology loaned to me as part of participation in this Activity and commit to return the same in good working order.
5. I hereby, for myself and for my heirs, next of kin, executors, administrators and assigns, fully release, waive and forever discharge any and all rights or Claims I may have, now or in the future, against any Released Party, even if the Claims are based on the carelessness, negligence or gross negligence of a Released Party or anyone else. Without limiting the foregoing, I further release any recourses which I may now or hereafter have resulting from any decision of any Released Party.
6. I agree not to sue any Released Party for Claims, even if the Claims arise from the carelessness, negligence or gross negligence of any Released Party or anyone else. I agree to indemnify (reimburse for any loss) and hold harmless each Released Party from any loss or liability (including any reasonable legal fees they may incur) defending any Claim made by me or anyone making a Claim on my behalf, even if the Claim is alleged to or did result from the carelessness or negligence of any Released Party or anyone else.
7. I am aware that there is no obligation for any person to provide me with medical care during the Activity. I understand and acknowledge that:
a. there are no aid stations available for the Activity.
b. if medical care is rendered to me, I consent to that care if I am unable to give my consent for any reason at the time the care is rendered.
8. I am aware that it is advisable to consult a physician prior to participating in the Activity. If I have consulted a physician, I have taken the physician’s advice.
9. No warranties or representations have been made to me about the Activity which are not stated on this form. I understand and intend that this document act as the broadest and most inclusive assumption of risk, waiver, release of liability, agreement not to sue and indemnity.
10. If any provision of this agreement shall be unlawful, void or for any reason unenforceable, then that provision shall be deemed severable from this agreement and shall not affect the validity and enforceability of any remaining provisions.
11. I have fully read and understand this agreement. I am aware that by signing this agreement, I am waiving certain legal rights I or my heirs, next of kin, executors, administrators and assigns may have against the Released Party.
I also understand that (please initial);
______ The scheduling and content of activities may be changed on occasion and that a qualified substitute may on occasion lead the class.
______ I will notify the instructor immediately of any pain and/or major discomfort felt during any activity.
______ If I am pregnant or plan to become pregnant during course of the Activity, I will inform the instructor and understand that I may be asked not to participate in the activity until after the birth and with the medical consent of my doctor.
BY SIGNING BELOW, Participant accepts and agrees to the terms and provisions contained in this agreement.
___________________________ ____________________
Signature
_______________________ ________________________
Date