Section I: Personal Information
Name/Phone of Emergency Contact:________________________________
Section II: Risk Assessment
Heart Disease YES NO
Shortness of Breath or Chest Pain YES NO Inhaler? (If yes, please bring it to every class)
High Blood Pressure YES NO
High Cholesterol Level YES NO
Significant Bone/Joint/Muscle Pain YES NO
Back Pain YES NO
Tobacco Use YES NO
Diabetes YES NO
Other, Please explain:_________________________________________________________
Are you active? YES NO
Activity or Exercise _____________________________________
Times per week _____________________________________
Are you currently taking any medication(s)? Yes No Type:______________________
SECTION III: AGREEMENT
IT IS YOUR RESPONSIBILITY TO INFORM THE INSTRUCTOR OF YOUR LIMITATIONS BEFORE CLASS BEGINS
I represent and warrant that I am in good physical health and do not suffer from any medical conditions which would limit my participation in the classes offered at BREATHE. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any of the yoga classes, programs, retreats, or workshops. I understand the risks associated with activities offered by BREATHE and I agree to follow all instructions so that I may safely participate in classes, workshops, retreats, or other activities. I hereby WAIVE AND RELEASE BREATHE, its owners, officers, employees, and instructors from any claim, demand, cause of action of any kind resulting from or related to my participation in the programs offered at the facility. In taking part in the yoga classes, workshops, retreats, or other activities at BREATHE, I understand and acknowledge that I am fully responsible for any and all risks, injuries, or damages, known or unknown, which might occur as a result of my participation in the classes, workshops, retreats, or other activities.
I have read the above release and wavier of liability and fully understand its content. I am legally competent to sign and voluntarily agree to the terms and conditions stated above.
Please practice mindfully and enjoy the many benefits of practicing yoga with BREATHE
If participant is under 18:
As Parent or Legal Guardian of___________________________________,I consent to the above terms and conditions.
Credit Card Information
BREATHE: A Family Yoga Center
Parent/Legal Guardian if patient is a minor:____________________________________
Name on Credit Card:_____________________________________________________
How would you prefer to receive an invoice: Email______Text_______Both_____
Your CC will be stored on file with BREATHE for future CC transactions until we are notified in writing to deactivate the above CC information. I give permission to keep this information on file and to charge my credit card as needed for services rendered, until notified in writing that I want this information destroyed and no longer used for services with BREATHE.
Signature:______________________________________________________________Thank you for your business.
There is a 3% surcharge for all CC transactions.