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Health Waiver & Intake

Please take a minute to fill in the following information.

First name

Last name

Pronouns (if you choose to share them)

Phone

Address

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Do you have a doctor’s permission to participate in physical activities?

Yes

Please specify anything I should know about. This could include injuries, health conditions, a trauma history, anything you think I should know before coming to class here.

How did you hear about Yoga in The Loft?

I the undersigned do hereby agree to the following: I am participating in yoga classes, health programs, workshops and/or other wellness, body work, therapy, exercise and healing arts activities (collectively, the “Activities”) offered by Jennifer Snowdon (“Teacher”).

I recognize that I must be in adequate physical and mental health to participate in the Activities. I understand that the Activities may require intense physical exertion, and I represent and warrant that I am physically fit enough to participate and I have no medical condition which would prevent my full participation in the Activities. I recognize that the Activities may cause or aggravate a physical injury or medical condition. I understand that it is my responsibility to consult with a physician before my participation in the Activities. If I have done so, I have taken the physician’s advice. I understand that the Teacher reserves the right to refuse my participation in any Activity on medical, fitness or any other grounds.
I am aware that my participation in the Activities could result in high blood pressure, fainting, heartbeat disorders, physical injury, heart attack or stroke and may aggravate pre-existing injuries. I understand that I could experience muscle, back, neck and other injuries as a result of my participation in the Activities. I understand my physical limitations and I am sufficiently self- aware to stop or modify my participation in any Activity before I become injured or aggravate a pre-existing injury.
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, including those which may result from the negligence of the Teacher.
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 Teacher (“Released Party”) that I may sustain as a result of participating in the Activities at the Studio even if the Claim arises from the negligence of Released Party or anyone else. I agree to indemnify and hold harmless Released Party from any loss, cost, 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 Released Party or anyone else.

I agree to the above terms and conditions

I am signing on behalf of my child

I give you permission to email me.

Signature

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