Yoga Waiver / New Student Form

Name

First NameLast Name

Birthday

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you ever practiced yoga before?

How often do you practice yoga?

If yes, What style of yoga have you practiced before?

On a scale of 1-10 (10 being the highest), how would you rate your level of daily activity?

On a scale of 1-10 (10 being the highest), how would you rate your level of daily stress?

What are your health goal(s) for your yoga practice?

What aspect(s) of yoga are you most interested in?

Please review the following list and check any health conditions that apply to you or have applied to you recently.

Other: explain below

Are you currently taking any medication? If so please list name(s) and reason:

Payment will be collected before class starts. Below choose your option of payment.

By signing this waiver, I agree and understand the following:

1. I authorize the collection and use of the above personal information as is required for therapeutic treatment and related administrative purpose. I understand that all my personal information is confidential and will not be released without my signed consent.

2. The practice of yoga or any other fitness activity has certain hazards and risks and by which it requires physical exertion that may cause physical injury.

3. I have been advised to consult with a medical physician prior to joining a yoga class, workshop, or any session.

4. In case that instructors provide physical adjustments, I understand that I have the option to opt-out by letting my instructor know my wish not have physical adjustments.

5. I hereby release, waive, discharge and hold harmless the institution, its directors, officers, staff, volunteers, affiliates, and partners from any and all liabilities arising from any untoward incident in my participation to any class, workshop, and relevant sessions which may result to injury, loss, damage, or death.

6. In the event that any dispute arises out of this agreement, and in the event that the dispute could not be resolved amicably, I agree that the dispute shall be resolved by mediation before a mutually agreed and selected mediator by both parties. In the event that a mediation proceeding fails to resolve the dispute, the matter shall be resolved with an arbitrator.

By signing this form, I hereby represent and warrant that I am physically fit and capable to participate for yoga classes, workshop, or activities. I agree and legally bind myself, with full understanding to the contents and meaning of the provisions above. I declare that I am over 18 years of age and fully capable in giving my consent.

Please practice mindfully and enjoy the benefits of practicing yoga.

Signature

Date