Yoga Waiver Liability Form

Waiver Liability Form
Please complete this form prior to your yoga session.

If questions do not apply to you, please answer N/A.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please specify how we may stay in contact with you to share upcoming events and classes (phone, email, or text).
I am 18 or older
Legal guardian name (if under 18 years old)
How did you hear about Kibwe Eshe Yoga & Wellness?

Have you practice yoga before?

If yes, for how long?
Emergency contact name and number

Please check any existing or past conditions. Check all that apply.
Asthma 2        Hip pain or discomfort 1   Neck/should pain 2   Back pain/soreness 2   Knee pain 1    Anxiety or depression 1
Joint pain or injury 1 Heart/circulatory problems 2
Seizures 1   Dizzy spells 2 High or low blood pressure 2

Please list any current limitations, pregnancy, or injuries.
Please list any other health concerns, allergies, or medical conditions that could cause concern during yoga session.
Please read and initial each agreement.

I understand that at any time during class, if I feel discomfort or strain, I can gently come out of the posture. I may rest at any time during class. It is important in yoga to listen to my body, and respect its limitations on any given day.   Initial*

I understand that yoga includes physical movements as well as an opportunity for relaxation and stress relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated.      Initial*

I understand that yoga is not a substitute for medical attention, examination, diagnosis, or treatment. I should consult my physician prior to beginning any activity program, including yoga. I recognize that it is my responsibility to notify my teacher of any serious illness (including Covid-19) or injury prior to every yoga class. I will not perform any postures to the extent of strain or pain.   Initial*

I accept that neither Kibwe Eshe Yoga & Wellness LLC (KEY), the instructor, nor hosting facility are liable for any injury, or damages, to person or property, resulting from taking KEY yoga class. Those under 18 years of age must have this form signed by a parent or guardian.
Initial *
I understand that the instructor may provide hands-on adjustments to improve form. I understand I have the right to refuse any adjustment, and if I do not wish to be touched, I will inform the instructor before class.
Initial
Date

MonthDayYear
Date
Signature
Should be Empty:

Waiver Liability Form

Please complete this form prior to your yoga session.