Waiver

NAME ............................................................

DATE OF BIRTH ........................................ 

MOBILE ........................................................

EMAIL ............................................................

EMERGENCY CONTACT & PHONE

......................................................................... 

 

WHAT ARE YOUR GOALS?     Please tick.

⃞ Increased flexibility

⃞ Increase core strength & stability

⃞ Improve posture & alignment

⃞ Enhance body awareness & mental concentration

⃞ Strengthen & tone muscles

⃞ Increase circulation & relieve tension

⃞ Add to your existing program

⃞ Find peace within your mind

⃞ Try something new

 

HAVE YOU CHECKED WITH YOUR DOCTOR?   YES   NO 

 

PLEASE LIST ANY MEDICAL PHYSICAL INJURIES, SURGERIES AND/OR CONDITIONS:

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• I UNDERSTAND THAT YOGA, PILATES, DANCE  & THE USE OF PROPS, COULD BE A POTENTIALLY HAZARDOUS ACTIVITY. 

• I HEREBY AGREE TO ASSUME AND ACCEPT ANY AND ALL RISKS OF INJURY OR EVEN DEATH.

• I UNDERSTAND THAT WHILE I PARTICIPATE IN PHYSICAL ACTIVITIES THIS MAY EXPOSE ME TO CERTAIN HEALTH RISKS BUT I DO SO AT MY OWN RISK. 

• I WILL NOT HOLD ‘ WILD AT HEART YOGA AND DANCE’  LIABLE FOR ANY INJURY THAT MAY OCCUR.

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SIGNATURE _________________________________________________ DATE ______  / ______  / __________