Health Information: Adult (print, complete and bring with you)
City, State, Zip _________________________________________________________
Home Phone ____________________Other phone (s)_________________________
Date of birth: _____________
E-mail if you would like updates: __________________________________________
Emergency contact (relationship and phone #): _______________________________
Male/Female (circle one) Age ____ Are you Pregnant?________
Circle and clarify any conditions that apply to you:
Disc Disease/ Osteoporosis ______________________________________________
Heart Conditions _____________________________________________________
Blood Pressure ______________________________________________________
Recent Injuries/Surgery _________________________________________________
Spinal Conditions ________________________________________________________
Describe your present state of health_______________________________________
Describe in detail and physical or mental conditions that would be helpful for your instructor to be aware of:
List any medications you are taking and the conditions you are taking them for (use back):
Do you have any questions relative to your full participation in class?
Lifespan Yoga™ Release and Waiver of Liability
I __________________________________(print name) hereby agree to the following:
- I am participating in yoga classes, health programs and/or workshops offered by Lifespan Yoga®. I will receive information and instruction about yoga and health. I realize 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, adjust the posture and ask for support from the teacher. I will continue to breathe smoothly.
- I understand it is my responsibility to consult with a physician prior to and regarding my participation in yoga classes, health programs and/or workshops. I represent and warrant that I am physically fit and I have no medical condition that would prevent my full participation in yoga classes, health programs and/or workshops. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions.
- In consideration of being permitted to participate in yoga classes, health programs and/or workshops, I assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the program.
- In further consideration of being permitted to participate in yoga classes, health programs and/or workshops, I knowingly, voluntarily, and expressly waive any claim I may have against Lifespan Yoga® for injury or damages that I may sustain as a result of participating in the program
- My heirs, legal representatives forever release, and I waive, discharge and convenient not to sue Lifespan Yoga® for any injury or death caused by their negligence or other acts.
I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above. I affirm that I alone am responsible to decide whether to practice yoga. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against Beth Daugherty or Lifespan Yoga®.
Signature of Participant _____________________________Date ______________________