Participant Agreement and Release Form
Which Roots & River Yoga event are you attending?
Saturday, March 8, 2025~ Worm Full Moon Night Hike & Sound Bath at Weverton Cliffs
Friday, April 11, 2025~ Pink Full Moon Night Hike & Sound Bath at Weverton Cliffs
Saturday, May 10, 2025~ Flower Moon Night Hike & Sound Bath at Weverton Cliffs
Sunday, June 8, 2025~ Strawberry Moon Night Hike & Sound Bath at Weverton Cliffs
Wednesday, July 16, 2025~ Buck Moon Night Hike & Sound Bath at Weverton Cliffs
Saturday, August 23, 2025 ~Waxing Crescent Sturgeon Moon Night Hike & Sound Bath
Saturday, September 6, 2025 ~ Corn Moon Night Hike & Sound Bath at Weverton Cliffs
Saturday, October 18, 2025 ~ Sunset Hike & Sound Bath at Weverton Cliffs
Saturday, November 8, 2025 ~ Beaver Moon Night Hike & Sound Bath at Weverton Cliffs
For other Imagine Wellbeing events, visit imaginebeingwell.org
First and Last Name of Participant
Part 1: Liability Release
You are responsible for your own well-being and safety during this event.
I acknowledge that outdoor activities in natural areas entail known and unanticipated risks that could result in injury. I agree and promise to accept responsibility for my own safety and well-being during this activity. I understand that I may at any time opt to not participate in any part of the activity should I feel that it is not safe, or simply do not want to participant for any reason.I voluntarily release and hold harmless Suzanne Cervarich, Lauren Lang, and Roots & River Yoga from any and all claims of liability which are in any way connected with my participation in this activity. If I have a medical condition or health concern I think the guides should be aware of, I will describe it on this form.
Yes, I agree to the above conditions.
No, I do not agree to the above conditions.
Part 2: Health Questionnaire
Date of Birth
Emergency Contact Name
Relationship to emergency contact
Emergency Contact Phone Number
Format: (000) 000-0000.
Do you wear a Medic Alert Tag or any other marker of a medical problem?
Please Select
No
Yes
If you do wear a medic alert tag, please describe:
Do you have allergic or anaphylactic reactions to anything, such as environmental substances, foods, drugs, insect bites or stings?
Please Select
No
Yes
If you do have allergic or anaphylactic reactions, please describe, and let us know if you carry an EpiPen or other fast-acting medication:
Do you have any other health-related disease, condition, or concern that program guides should be aware of?
Please Select
No
Yes
If you have any other health related conditions or concerns, please describe
Is there anything else you would like us to know?
By signing this form, I certify that the information I wrote on this form is accurate and complete. I agree to communicate fully with Suzanne Cervarich and Lauren Lang about any health concerns that may arise. I give my permission to Suzanne Cervarich and Lauren Lang to seek emergency medical diagnosis or treatment for me in the event that I am unconscious or unable to make my own decisions. I understand that should I need medical care for any reason while participating in this event, the role of Suzanne Cervarich and Lauren Lang will be limited to emergency first-aid and either transportation to the nearest medical facility or arranging emergency transport.
SIGNATURE
Part 3: Photo and Media Release
With your permission, Suzanne Cervarich and Lauren Lang may take photographs of you and the group during the activities. We would like your permission to use these photographs in promotional materials which may include social media, website, printed flyers, and videos. If you are not comfortable with having photos taken that include you and possibly used in these ways, we prefer that you mark "No" in the box below; We want you to have a relaxed and stress-free experience.
Please Select
Yes, you may take photographs of me and use them as described above.
No, I prefer not to be photographed.
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Year
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Signature
City of Residence
Submit
Should be Empty: