EMBODY DIVING WELLNESS

Waiver

Name *

First

Last

Phone Number *

Email *

Date of Birth *

Emergency Contact's Name *

First

Last

Emergency Contact's Relationship to You *

Emergency Contact's Phone Number *

Medical History *

Please list all health impairments, injuries, surgeries, medications.

Yoga History

If new to yoga, what are your interests, concerns, or questions. If you practice, please share how long & type practicing.

There is an inherent risk associated with any exercise program including my voluntary participation in yoga that may result in injury. *

I understand

the components of exercise/yoga are potentially hazardous activities and may cause injury. *

I understand and am aware

I, hereby assume all responsibility for my participation in any exercise/yoga or activity associated with Embody Divine Wellness. *

I understand

I, my heirs, or legal representatives, do hereby waive and release Embody Divine Wellness its teachers and employees from all liability and responsibility from injury, accident, illness, legal and medical fees sustained now or in the future. *

I acknowledge

I am physically well and suffering from no medical problems, conditions, impairments, diseases, or any other illness that would prevent my participation or increase my risk of injury because of partaking in any exercise/yoga program. *

I certify the above statement to be true

I have either had a physical examination and/or have been given permission from my physician to participate in a meditative, yoga-based exercise program or that I have decided to participate in an exercise program voluntarily. *

I acknowledge

Embody Divine Wellness will provide an area for personal belongings to be held during class, however, I agree that Embody Divine Wellness is in no way responsible for the loss or damage of my belongings while I attend class. *

I understand

I have read this waiver of liability form. I fully understand its terms and conditions and understand that I am giving up my right to sue Embody Divine Wellness, its teachers, and employees. *

I acknowledge

I am signing this agreement voluntarily and intend by my signature to be a complete and unconditional release of liability to the greatest extent allowable by law. *

I acknowledge

How did you hear about Embody Divine Wellness?