Waiver & Par Q Form
AGREEMENT OF RELEASE AND WAIVER OF LIABILITY
251 Grant Drive, New Liskeard, ON P0J 1P0
705 -648-1522 ~ firstname.lastname@example.org
Authorization of this Document will waive certain Legal Rights, including the right to sue.
I, (please print)____________________________________________, hereby agree to the following:
1. That I am participating in the Yoga classes, health programs, workshops or services offered by YogArt during which I will receive information and instruction or other services offered pertaining to Yoga and health. I recognise that Yoga requires 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 Yoga classes, health programs, workshops or services. I represent and warrant that I am physically fit and I have no medical conditions, which would prevent my full participation in the Yoga classes, health programs, workshops or services.
3. In consideration of being permitted to participate or receiving services, 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 or receiving any services.
4. In further consideration of being permitted to participate in the Yoga classes, I knowingly, voluntarily and expressly waive any claim I may have against YogArt for injury or damages that I may sustain as a result of participating in the program or from receiving any services.
5. I, and my heirs or legal representatives forever release, waive, discharge and covenant not to sue YogArt for injury or death caused by their negligence or other acts.
6. That I am participating in Suspension Yoga classes offered by YogArt Studio during which I will receive information and instruction about the Yogi Gym Suspension Sling.
7. The Yogi Gym Suspension Sling is not a substitute for medical attention, examination, diagnosis or treatment. I understand that it is my responsibility to consult with my physician prior to and regarding my participation in these classes if I have an existing medical condition or injury.
8. I realize that it is my responsibility to notify my instructor of any illnesses or injuries before every Suspension class.
9. I understand that YogArt Suspension yoga classes involve physical activity and even with the best of intentions it is possible that injuries may result or prior conditions may be aggravated. If I should experience any discomfort or strain, I will listen to my body, gently come out of the pose and ask for support from my instructor.
10. In consideration of being permitted to participate in Suspension yoga classes, I freely accept and assume full responsibility for any risks, injuries or damages, known or unknown, which might incur as a result of my participation in the program.
11. I hereby knowingly, voluntarily and expressly release my instructor, Anny St. Jean or any other teachers conducting classes on her behalf of YogArt, from any and all liability for any injury or damages that I may sustain as a result of participating in the classes.
12. I agree to waive any and all claims, actions or causes of any kind whatsoever which I or my heirs, executors, estate trustee, administrators, assigns or representatives may have in the future against Anny St. Jean, YogArt and / or YogArt Employees.
I have read and fully understand the above release and voluntarily agree to the terms and conditions stated above.
_____________ _______________________________ ____________________________
DATE SIGNATURE OF PARTICIPANT SIGNATURE OF PARENT (if under 18)
DATE OF BIRTH ___________________________ AGE: _________________
CITY, POSTAL CODE_________________________________________________________________________
PHONE NUMBERS: HOME____________________WORK_____________________CELL________________
WOULD YOU LIKE TO RECEIVE EMAILS WITH REGARDS TO YOGA RELATED TOPICS AND LINKS____________
Do you have any chronic conditions, injuries or illnesses we should know about?
If yes, what date/year? __________________________________________________________
Please circle all applicable conditions:
· heart condition/problem
· are pregnant
· have diabetes
· multiple sclerosis
high blood pressure
· detached retina
· spinal injuries either cervical, thoracic, or lumbar
· sinus problems
· carpal tunnel
· knee injuries
· chronic problems
ANY condition that would need a doctor’s approval to participate in practicing Yoga? ________________________________________________________________________________________
Are you currently under a doctor’s care? ________________________________________________________________________________________
Do you regularly take medication (s) that would affect your participation in Yoga? If answered yes, what? ________________________________________________________________________________________
· In the event that YogArt or news media take pictures of program activities to be used in YogArt publicity or on our web-site: please initial.
_____Yes, YogArt has my permission to use pictures of myself or my child.
_____ No, YogArt may not use pictures of myself or my child.