Amy Dieterle Yoga & Wellness
AGREEMENT OF RELEASE AND WAIVER OF LIABILITY FOR ONLINE AND/OR IN-PERSON YOGA CLASS
Date of Birth: ___/___/_____
City: ____________________________ State: _________ Zip:______________
Emergency Contact Name:
Emergency Contact Phone:
Do you have any physical limitations that could be aggravated by exercise (i.e. back, neck, shoulder or knee problems)? If so, please explain:
It is your responsibility to inform the instructor of limitations before class begins.
Please read the following and ask if you have any questions. I understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor. I assume full responsibility for any and all damages, which may incur through participation. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. By signing, I affirm that a licensed physician has verified my good health and physical condition to participate in such a fitness program. In addition, I will make the instructor aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician's approval to participate. I also affirm that I alone am responsible to decide whether to practice yoga and participation is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Amy Dieterle, its owners, officers, employees, and instructors. I have read and fully understand and agree to the above terms of this Agreement and Release of Waiver of Liability. I am signing this agreement voluntarily and recognize that my signature serves as complete and unconditional release of all liability to the greatest extent allowed by law.
Print Participant’s Name:
Signature of Participant (or legal guardian):