Sacred Earth Healing Arts
Yoga
Agreement of Release and Waiver Liability Form
Name:_____________________________________
Address:___________________________________
City:___________________ Postal Code:______________
Phone #:____________________________
Email: _________________Would you like to receive emails on upcoming workshops? YES/NO
Date of Birth: _________________________
Emergency Contact:_______________________ Phone #:__________________
Have you practiced yoga before? YES / NO How many hours a week?________
Describe your level of experience with yoga: circle Beginner Intermediate Advanced
Do you have any of the following conditions that your instructor should be aware of: circle
Heart/Circulatory Problems Dizzy/Fainting Spells Chronic Pain
High/Low Blood Pressure Asthma Diabetes Epilepsy/Seizures Multiple Sclerosis Fibromyalgia
Neck/Back/Spine Injury: __________________________________
Pregnancy: How many weeks?______
Other Medical conditions, injuries or disability: _____________________
Recent surgery or accident: ____________________________________
Any person participating in a yoga class, private session or yoga workshop offered by Sacred Earth
Healing Arts has been asked to and agrees to the terms below at the time of registration.
I, ____________________________________________, hereby agree to the following:
1. I am participating in yoga classes, health programs, workshops and other wellness, exercise and healing arts activities (collectively, the “Activities”) offered by Sacred Earth Healing Arts (“Studio”) and/or its owners, instructors, teachers, workshop, employees and independent contractors.
2. I recognize that I must be in good physical and mental health to participate in the Activities. I understand that the Activities may require physical exertion, and I represent and warrant that I am physically fit and I have no medical condition which would prevent my full participation in the Activities. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Activities. If I have consulted a physician, I have taken the physician’s advice. I understand that the Studio reserves the right in it’s absolute discretion to refuse my participation in an Activity on medical, fitness or other grounds.
3. I am in proper physical condition to participate in the Activities, and I am aware that participation could, in some circumstances, result in abnormal blood pressure, fainting, heartbeat disorders, physical injury and potentially heart attack. I also understand that I could experience muscle, back and other injuries during exercise. I understand my physical limitations and am sufficiently self-aware to stop physical activity before I become ill or injured. I understand that it is my continuing responsibility to inform the Studio of any previous medical conditions, injuries or surgeries prior to my first class and any future changes to my medical condition.
4. In consideration of being permitted to participate in the Activities, 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 Activities at the Studio.
5. In further consideration of being permitted to participate in the Activities, I knowingly, voluntarily and expressly waive any “Claim” (as defined below) I may have against the Studio, its owners, members, employees, and/or its instructors, teachers, volunteer staff, interns, workshop presenters, independent contractors and the landlord of the Studio (each, a “Released Party”) for any Claim that I may sustain as a result of participating in the Activities at the Studio even if the Claim arises from the negligence of any Released Party or anyone else. I agree to indemnify and hold harmless each Released Party from any loss or liability incurred in defending any Claim made by me or anyone making a Claim on my behalf, even if the Claim is alleged to or did result from the negligence of any Released Party or anyone else. “Claim” includes but is not limited to any and all liabilities, claims, demands, expenses, fees, legal actions, rights of actions for damages, personal injury, mental suffering and distress, or death that I may suffer, my children may suffer or that my unborn child may suffer (including any legal fees or expenses) in connection with participation in any Activity.
6. I, my heirs or legal representatives forever release, waive, discharge and covenant not to sue any Released Party for any Claim caused by any negligence or other acts of a Released Party.
7. I hereby understand that the Studio from time to time may photograph or video classes or events occurring at its studios and place such photographs and videos on its Website. I hereby consent to the use of my image that may appear in any such photograph or video. Acknowledgment of these photos and videos will be told to me beforehand.
8. This agreement shall be construed in accordance with, and governed by, the laws of the Province of British Columbia. I acknowledge that I have carefully read this release and waiver of liability and fully understand its contents. I voluntarily and knowingly agree to the terms and conditions stated herein. I am aware that by signing this release and waiver of liability, I am giving up substantial rights, including my right to sue and certain legal rights my heirs, next of kin, executors, administrators and assigns may have against any Released Party.
Name of participant____________________________________________Date_______
If participant is under 18:
As legal guardian of ________________________________,
I consent to the above Waiver of Release and Assumption of Liability
Signature _____________________________________________
