Waiver Form - Wonders Counseling printable pdf download

Wonders Wellness, LLC

Yoga, Meditation and Tai Chi

Waiver Form

SECTION I: PERSONAL INFORMATION

* Name:_________________________________________________________________________________________________________________

*Address: __________________________________________*City: ______________________*Province: ______ *Postal Code: _______________

Primary Phone: ________________________

*E-mail: _______________________________________________________________

(Cell preferred)

*Emergency Contact Name: _________________________________________________ *Emergency Contact Phone: _______________________

(* denotes required fields)

SECTION II: RISK ASSESSMENT

Heart Disease

YES NO

Shortness of Breath or Chest Pain

YES NO Inhaler? YES NO

(if “yes”, please bring it to every class)

High Blood Pressure

YES NO Levels:

____________________________

High Cholesterol Level

YES NO

Significant Bone/Joint/Muscle Pain

YES NO Location: ____________________________

Back Pain

YES NO

Cigarette Smoking

YES NO Levels:

____________________________

Abnormal Resting EKG

YES NO

Diabetes

YES NO Insulin Dependent? YES NO

Any other? Please explain: _____________________________________________________________________________________

Are you active?

YES NO

Activity or Exercise:

___________________________________

Times per week:

___________

Minutes per session:

___________

Are you currently taking any medication(s)?

YES NO Type: ____________________________________________

SECTION III: AGREEMENT

1. In consideration of participating in yoga, meditation, Tai Chi (circle one or more if applicable) I agree and acknowledge that I am fully aware that

participation in this activity involve risks and I accept all the risks of participating, even if the risks are created by the carelessness, negligence or

gross negligence of a Released Party (as defined below) or anyone else.

2. “Claims” includes but is not limited to any and all liabilities, claims, demands, legal actions, rights of actions for damages, personal injury or

Wonders Wellness, LLC and Lynn Louise Wonders

death in connection with participation in the Activity. “Released Party” means

or any of its affiliates, franchisees and their respective representatives, directors, officers, agents, employees or volunteer staff.

3. I agree and acknowledge that:

a. I am in proper physical condition to participate in the Activity, and am aware that participation could, in some circumstances, result in physical

injury, serious physical injury or death.

b. I understand my physical limitations and am sufficiently self-aware to stop physical activity before I become ill or injured.

c. I am aware that if the Activity occurs outdoors, the streets adjourning the area of the Activity are open to regular vehicular traffic during the

Activity and I will obey all traffic laws and regulations.

4. I accept full responsibility for any product or technology loaned to me as part of participation in this Activity and commit to return the same in

good working order.

Waiver Form - Wonders Counseling

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