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Yoga Waiver & Release

First Name

Last Name

Date of Birth

Phone

Email

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

No

Yes

Emergency Contact Name

Emergency Contact Phone

Please describe your previous yoga and/or fitness experience:

I am participating in the Power Yoga Vinyasa Class/Workshop, offered by Kirsten Ferguson or any substitute yoga instructor, during which I will receive information and instruction about yoga and health.

I recognize that yoga may require some physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of and accept the risks and hazards involved. In consideration of being permitted to participate in the Power Yoga Class or Workshop, 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 program. I am responsible for modifying the practice to meet my physical abilities.

I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Power Yoga class or Workshop. 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 understand that, although Kirsten Ferguson is a chiropractic doctor, the information and instruction received during my participation in this program is not to be construed as medical advice or diagnosis. I further agree that a medical opinion from Dr. Ferguson within her scope of practice, is only available directly through a complete examination in her office at Fern Creek Chiropractic Center.

I represent and warrant that I am physically fit and I have no medical condition which would prevent my full participation in the Power Yoga Class/Workshop.

In further consideration of being permitted to participate in the Power Yoga Class/Workshop, I knowingly, voluntarily and expressly waive any claim I may have against Kirsten Ferguson or any substitute yoga instructor for any injury or damages that I may sustain as a result of participating in the program. I, my heirs or legal representatives, forever release, waive, discharge and covenant negligence or other acts.

I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. 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

I irrevocably grant Kirsten Ferguson, Fern Creek Chiropractic, VitalityDoc the right to use my name, likeness, photos, reproduction or testimonials for promotional purposes.

I declare that the info I’ve provided is accurate & complete

Your Signature

Is registrant under 18 years of age?

No

Yes

Legal Guardian Signature

Legal Guardian Phone

Thanks for submitting!