New Student Information Waiver
Date
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Approximate Birthday: (ie: month/day and approx year)
Have you ever participated in yoga?
Yes
No
If Yes, when and how often?
Every day
2-3 times/week
once/week
once/month
a few times/year
Comments:
Do you have any medical restrictions or conditions?
*
Yes
No
If Yes, Please explain:
Are you currently taking any medications?
Yes
No
If so, please list:
What are you looking for from yoga?
Stress Management
Strengthening
Better Balance
More Flexibility
Spiritual Health
Community
All the Above
Other:
Yoga Activity Disclaimer - I hereby consent as a participant in Yoga classes and agree to assume all of the risks involved. I understand that Yoga does not provide medical insurance relative to accidents, injuries, and/or death as a result of program related activities; and that I cannot hold Lisa Gregor or the Sherman Sr. Center personally responsible for any liability. (Enter initials below)
*
(Enter Initials Above)
I recognize that any form of physical activity is a potentially hazardous one, and that they involve a risk of possible injury or even death. I hereby affirm that I am voluntarily participating in these activities with the knowledge of the risk involved. I agree to expressly assume and accept any and all risks of injury and/or death.
*
(Enter Initials Above)
I further recognize, although vaccines, social distancing and practicing yoga outdoors minimizes risk, there is a slight risk of contracting Covid-19. I hereby affirm I am aware of this risk and assume and accept all risks.
*
(Enter Initials Above)
I hereby affirm myself to be physically sound and suffering from no condition, aliment, impairment, disease, or other illness that would prevent my participation in Yoga activities, I declare that I have disclosed any and all medical history to the above Yoga Instructor relevant to participation.
*
(Enter Initials Above)
Signature
*
By signing my full name above, I acknowledge my electronic signature that I have read and understand the above.
Clear
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform