Information and Waiver of Liability

Information and Waiver of Liability

A.) GENERAL INFORMATION

Name:______Birth Date: ______

Street Address: ______

City: ______State: ______Zip: ______

Phone: ______E-mail Address: ______

Emergency Contact: ______Emergency Contact Phone: ______

B.) SPORTS/MEDICAL HISTORY

What is your experience with yoga? (circle one) novice intermediate advanced

Describe your physical activity on a typical day: ______

______

Are you affected by any of the following:

* Heart problems of any type? Yes No

* High Blood Pressure? Yes No

* Glaucoma? Yes No

* High Blood Pressure? Yes No

* Arthritis or another bone or joint problem? Yes No

* Diabetes? Yes No

* Pregnancy? Yes No

* Any other disease or health condition not listed above? Yes no

If yes to any of the above, please describe: ______

______

C.) Affirmation of Understanding and Acceptance of the Risks of the Practice of Yoga

Notwithstanding the medical information provided above, client hereby understands that although instructor has training and experience regarding the practice of yoga, she has no special knowledge regarding any possible medical or physical or other condition which may affect the client's performance, or which may be in some way caused or exacerbated by the client's performance in this yoga class. Indeed, Instructor is hereby relying on the client's consultation with a physician prior to engaging in the practice of yoga, and regarding any issue which may arise during the practice of yoga. Client understands that the practice of yoga requires one’s own understanding of one's body, and one's willingness to not 'push one beyond one's limits’. Client understands that, even when respecting one's own limitations, it is possible that yoga could exacerbate, or be bad for, any medical condition, and could result in serious medical problems. Indeed, yoga is not safe for persons with certain medical conditions. Even if one has no prior medical condition, the practice of yoga could result in serious and un-forseen medical problems, including death or serious physical injury. I hereby affirm that I understand and accept those risks.

D.) WAIVER OF LIABILITY

I agree to the following:

1.  The information I have provided above is complete and accurate.

2.  I understand that it is my responsibility to consult with a physician prior to and regarding my participation in yoga exercise. I understand my physical limitations and am sufficiently self-aware to stop physical activity before I become ill or injured. I represent and warrant that I am physically fit and have no medical conditions that would prevent me from participation in yoga sessions.

3.  I understand that there is a risk of physical injury in performing yoga and that yoga is not a substitute for medical diagnosis or treatment. Yoga is not recommended with certain medical conditions. I affirm that I alone am responsible to decide whether to practice yoga. I agree to assume the risk of taking yoga classes and waive any claims that I may have against the instructor, Nicole Janik.

First Name: ______Last Name: ______

Signature: ______Date: ______

Signature of Parent/Guardian: ______