EMAIL.____________________________________HOME PHONE _____________________ CELL PHONE_________________
(we send you one small newsletter a month and will never share your email address with a third party)
How did you hear about Omniji Yoga Therapy? (of general interest to us!)
☐poster ☐internet search☐Facebook☐friend ________________ ☐other __________________
Are there any injuries, ailments, or medications that the instructor should know about
I, (Participant name) ___________________________, agree to the following:
YES NOPlease Check The Appropriate Box
☐ ☐ Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
☐ ☐ Do you feel pain in your chest when you do physical activity?
☐ ☐ In the past month, have you had chest pain when you were not doing physical activity?
☐ ☐ Do you lose your balance because of dizziness or do you ever lose consciousness?
☐ ☐ Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
If yes please explain:____________________________________________________________________________________
☐ ☐ Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Please list: _____________________________________________________________________________________________
☐ ☐ Do you know of any other reason why you should not do physical activity? ___________________________________
AWARENESS OF RISKS.
• I acknowledge that the instruction offered by Monica Angelatos limited to that of instruction in basic, fitness training and Thai Massage.
• I acknowledge that there are risks associated with participation in the activities and programs offered or sponsored Monica Angelatos, I have informed myself and understand the risks associated with my participation in these activities and programs and (where applicable) my use of the facilities, including the risk of personal injury, and I freely accept these risks.
• I understand that I am free to withdraw from or reduce my participation in the activities and programs offered or sponsored by Monica Angelatos at any time.
• I am not aware of any medical condition that would affect my ability to participate in the activities and programs offered or sponsored by Monica Angelatos. If I have any concerns about my medical condition. I will consult with my physician before participating in the activities and programs offered by Monica Angelatos.
RELEASE AND WAIVER.
In consideration of the acceptance of my registration for the activities and programs offered or sponsored by Monica Angelatos, I hereby for myself, my heirs, executors, administrators, or any others who may claim on my behalf, promise not to sue, and hereby waive, release and discharge Monica Angelatos and anyone acting for or on its behalf, from any and all claims of liability for personal injury, illness, loss of life or property damage of any kind or nature, arising out of or sustained in the course of my participation in the activities and programs offered or sponsored by Monica Angelatosor related events both on and off of the Premises where the programming is offered. This Release and Waiver applies to all claims, foreseen or unforeseen, including negligence and breach of statutory or other duty of care (including that owed under The Occupier’s Liability Act).
I agree that this Agreement and Release and Waiver is intended to be as broad and inclusive as permitted by law. Any provision found to be invalid or unenforceable by a court shall not affect the validity or enforceability of any other provision.
I have read this document carefully and acknowledge that I have complete knowledge and understanding of its contents. I recognize that by signing this document I am waiving certain legal rights, including the right to sue. I am signing this document voluntarily.
Participant Signature:________________________________ Date: _______________________
If the participant is under the age of 18 years:
As legal guardian of (print name):____________________________________,I consent to stated conditions and terms.
Signature of Parent/Guardian:________________________________ Date: _____________________