Yoga Agreement of Release and Waiver of Liability
Name: {name}
Home Address: {address}
Email: {name}
Phone: {phone}
Date of Birth: {dob}
Emergency Contact Name: {contact_name}
Phone: {contact_phone}
Do you have any of the following conditions that your instructor should be aware of:
Heart/Circulatory Problems
Epilepsy/Seizures
Dizzy spells/Fainting
High or Low Blood Pressure
Pregnancy
Diabetes
Asthma
Neck/Back/Spine injury:
Joint injury (ankle, knee, hip, elbow, shoulder) :
Muscular Injury:
Other medical conditions, injury, or disability:
Recent Surgery:
Yoga Level:
Beginner
Intermediate
Advanced
By completing and signing this form, I hereby agree to the following:
1. That I am participating in a Yoga Class, Workshop, or Pre-‐ registered yoga session offered by The Floating Fox during which I will receive information/instruction about Yoga. I recognize that yoga may require some physical exertion, which may be strenuous and may cause physical injury. I am fully aware of the risks and/or hazards involved.
2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Yoga Class, Workshop, or Pre-‐registered yoga session. I certify that I am physically fit and I have no medical condition, which would prevent my full participation in the Yoga Class, Workshop or Pre-‐registered yoga session.
3. I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in any yoga program at The Floating Fox, including hot or warm temperature yoga.
4. I knowingly, voluntarily and expressly waive any claim that I may have against The Floating Fox, its instructors and staff, and its owners, for any injury, death or damages that I may sustain as a result of being in the The Floating Fox facility or as a result of participating in a Yoga Class, Workshop or Pre-‐registered yoga session; including loss that may be caused by the negligence of the released party.
5. I release and discharge The Floating Fox, its directors, owners, staff and its instructors from any and all liability, claim, demand or action that I may have related to the loss, theft or damage of any of my personal property while at the The Floating Fox facility.
6. I, my heirs or legal representatives, forever release, waive, discharge and covenant negligence or other acts.
I have read the above release and waiver of liability and fully understand its contents. I am 18 years of age or older and voluntarily agree to the terms and conditions stated above.
Date: {sign_date}
If the participant is under 18 years of age: As a legal guardian of: , I consent to the above conditions and terms.
Signature of parent/guardian:
Date: {sign_date}