MGW Contact and Consent Form (Teen/Tween)

Contact Info

Easy Peasy
Name of Student

First NameLast Name
Name of Parent/Guardian

First NameLast Name
Parent/Guardian Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Phone Number

Area CodePhone Number
Emergency Contact Name (if different from above Parent/guardian):

First NameLast Name
Emergency Contact Phone Number:

Area CodePhone Number
Yoga is teaches skills that integrate physical, mental, emotional and spiritual well-being and balance. Mary Golden Wellness prioritizes the values of safety, trust-building, compassionate awareness, and personal empowerment. During Tween/Teen Confidence Building Mini Yoga Camp, each registrant will learn yoga poses and health-promoting techniques at their own pace in a group setting. Please communicate any concerns or issues with your teacher prior to begining or as they come up. Thank you for joining!
Would you like to join my monthly Newsletter?
What is your current self-care regimen? (ie: physical fitness, nutrition, wellness programs etc.)
Does your Tween/Teen have any allergies? (If so, please list in the field below).
Please list any Health Conditions, Limitations, Injuries or Recent Surgeries along with dates:
Consent Form

Thank you for filling this out and taking the lead in supporting your wellness!
Yoga and wellness coaching is an individual experience performed under the guidance of a certified instructor. I understand that I am empowered as the decision-maker for my own well-being but it is also wise to check in with my healthcare provider before starting a new healthcare, fitness or wellness regimen. If at any point, I feel overexertion, pain or fatigue, it is my responsibility to respect my own limitations, inform my instructor and rest before continuing.

In any physical activity, risk of serious physical injury is possible. I realize that I am participating in this program at my own risk. It is not a substitute for medical diagnosis and treatment. To the best of my knowledge, I have NO medical condition, which would prevent me from taking part in the aforementioned activities. I assume responsibility for any risk or injury I may sustain as a result of my participation. I have read the entirety of this document and understand its contents. I agree to the terms and conditions stated above. My signature is binding to this liability and this form from this day forth.

I give consent to have photos of participant taken and shared for promotional purposes. Thank you.
Parent/Guardian E-Signature
Date

MonthDayYear
Date
Should be Empty:

Contact Info

Consent Form