AGREEMENT OF RELEASE AND WAIVER OF LIABILITY FORM
I, , hereby agree to the following:
1. That I am participating in the Yoga Class/Workshop, offered by Jnanadevelopment, Dominic Francis-Smith, during which I will receive information and instruction about yoga and health. I recognize that yoga may require some physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of the risks and 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 or Workshop. I represent and warrant that I am physically fit and I have no medical condition which would prevent my full participation in the Yoga Class/Workshop.
3. In consideration of being permitted to participate in the Yoga Class or Workshop, 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 the program.
4. In further consideration of being permitted to participate in the Yoga Class/Workshop, I knowingly, voluntarily and expressly waive any claim I may have against Jnanadevelopmet or Dominic Francis-Smith (Jnandev), its owners, teachers and class/workshop Sponsor, for any injury or damages that I may sustain as a result of participating in the program.
5. 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 as well as the Refund/Cancellation and Make-up Class Policies. I voluntarily agree to the terms and conditions stated above.
REGISTRANT’S NAME AND SIGNATURE:
If registrant is under 18 a legal guardian’s authorization is required:
AS LEGAL GUARDIAN OF I CONSENT TO THE ABOVE TERMS AND CONDITIONS.
Adult Yoga Disclaimer
Dear Student: Please complete this form so we may review it prior to your first Yoga class. It will allow us to properly assess your personal needs. If you have any questions, please feel free to ask. Your sensitive details will be kept private and confidential.
Is this your first Yoga class? If not, please explain:
General Health Information: Do you have any of the following conditions?
___ Pregnant ___ Contact Lenses ___ Varicose Veins ___ Sinus Problems ___ High Blood Pressure ___ Weight Loss or Gain ___ Fibromyalgia
___ Sensitivities (Please explain below) ___
Ailments of Lungs (What type?) Arthritis (Where?) Back pain lower, middle, upper? Pain or Discomfort in any part of your body If yes, where? ______________________ Other ____________________
Emotional Imbalance ___ Anxiety ___ Female/Male Disorders
(Please explain below)
Explanationofanysensitivities,disorders, or pain: ____________________________________________ ______________________________________________________________________________________ Any recent or past accidents or injuries? If yes, please explain how the accident or injury has affected your body: _______________________________________________________________________________________ Are you presently taking medication? If so, what is the name of the medication? Do you experience any side effects? ___________________________________________________________________________ ______________________________________________________________________________________ For those who require special attention, have you contacted your Doctor prior to attending Yoga class? ______________________________________________________________________________________ Please consult your Doctor before starting Yoga if you have undergone any form of surgery or are under heavy medication.
Other necessary information in regards to your health, please explain: ______________________________ ______________________________________________________________________________________
I, ___________________________ , hereby release Dominic Francis-Smith (Jnandev). Jnanadevelopment “The School of Yoga” and all Instructors and Teachers (of Jnanadevelopment “The School of Yoga”) of all liability and responsibilities pertaining to Yoga classes. I am 18 years of age or older and understand this disclaimer.
Signed: ______________________________ Name: ____________________________________
Dated: _______________________________ Address: ___________________________________ ___________________________________
Class: ________________________________ Instructor: ____________________________
Phone: _______________email: _______________
ORIGINAL – HEAD OFFICE / COPY - INSTRUCTOR