Health Waiver Form Meditation

Email*

Confirmation Emailexample@example.com

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of birth*

Date

Best Contact Number?*

No dashes

Emergency contact name / relationship*

Emergency Contact Number?*

No dashes

Date of Meditation*

Date

Do you take any of the following medications or supplements regularly? Please check all that you have taken within the past 3 (three) months.*

Please list ANY and ALL other prescription, over-the-counter and/or natural medications that you are taking.*

If you are taking any medications, please provide details (medication name, dosage, etc.)

Do you have allergies? Include medications, foods, animals, environment.

Have you had any recent accidents, hospitalizations, operations, or illnesses?*

YESNO

If YES, please explain.

Do you have asthma?*

YESNO

If you have asthma, please list medications you take for it and the frequency of their use.

Do you have diabetes?*

YESNO

If you have diabetes, please list medications you take for it and the frequency of their use.

Do you have blood pressure issues?*

YESNO

If you have blood pressure issues, please list medications you take for it and the frequency of their use.

Do you have a history of other heart problems?*

YESNO

If you have a history of heart issues, please provide details and list the medications you take for it and the frequency of their use.

Have you ever had a TIA or a stroke (CVA)?*

YESNO

If yes to the above, please provide details.

Are you, or could you be pregnant?*

YESNO

Have you ever had a seizure?*

YESNO

If yes to the above, please provide details.

Have you ever been diagnosed with (check all that apply):*

If you checked any of the above, please provide details.

Do you have any other medical, health or psychological issues that may impact your participation in this meditation?*

YESNO

If YES to the above, please provide details.

Please state any other physical or mental limitations or restrictions of which you are aware.

If you have no such limitations, please type your initials below.*

Waiver of Liability

PLEASE TYPE YOUR NAME BELOW AS YOUR SIGNATURE.

In consideration of being allowed to participate in this event, I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the event's leader, organizewrs, hosots and partricipants from any and all liability, claims, demands, or course of actionj whatsoever arising out of, or related to any loss, dfanage, injury, including death, that may be sustained by me, or to any property belonging to me whether caused by the negligence of release, or otherwise, while participating in this event, or while in, or on or upon the premises where the event is being conducted.

To the best of my knowledge, I am in good physical condition and I am not aware of any physical or physiological infirmity that woukld place me at risk to participate in any way with the meditation activities. I am fully aware of the risks and hazards connected with this event.

I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISK OF LOSS, PROPERTY DAMAGE OR PERSONAL INJKURY, INCLUDING DEATH, that maybe sustained by me, or any loss or damage to property owned by me as a result of being engaged inj the event's activities whether caused by the negligence of release, or otherwise. In signing this release, I acknowledge and represent that I have read, understood and signed the form voluntarily. I am an adult, of at least nineteen years of age or older, and fully competent; and I execute the Release for full, adequate and complete considerations fully intending to be bound by same. This waiver applies ot all present and future work with these leaders.

YOUR NAME AS YOUR SIGNATURE IN THIS FORMAT: /s/ Your Full Name: EXAMPLE: /s/John Smith *

Today's date:*

Date

Please verify that you are human*

Health Waiver Form for Meditation