Name: ________________________________ Telephone: __________________________
Address: _______________________________E-mail address: _______________________
Medical Alert (injuries, physical limitations, ailments, etc.). Any health concerns that may affect your yoga practice. Please include joint and muscle injuries, and weaknesses as well as systemic conditions (untreated high blood pressure, diabetes, MS, etc.). Some yoga postures and breathing exercises are contraindicated for conditions such as high blood pressure.
Emergency Contact (name, #):___________________Allergies: ____________________
Classes you are interested in attending? _______________________________________
How did you hear about Welcome Mat Family Yoga,
Would you like to receive email announcements and class information from Welcome Mat Family Yoga, LLC? Yes No
How often do you practice yoga? (Circle one) DAILY WEEKLY MONTHLY, BEEN AWHILE, NEVER
Style(s) of yoga practiced most frequently: (circle all that apply)
Hatha Ashtanga Vinyasa/Flow Iyengar Power Anusara Bikram/Hot Forrest
Kundalini Gentle Restorative Yin Other: ___________________________________
What are your goals/expectations for your yoga practice? What benefits are you looking for? (Circle all that apply, explain)
Strength training Flexibility Balance Stress relief Address health concern Alternative therapy Improve fitness Weight management Increase well-being Injury rehabilitation other/ Explain: ________________________________________________________________
I have read the above information and have stated all my previous and current known medical conditions. I take it upon myself to update my instructor regarding any changes in my condition.
Student Signature_________________________________ Date: _______________
Liability Disclaimer and Notices: PLEASE READ CAREFULLY
The classes taught at/by Welcome Mat Family Yoga LLC, are led by trained, qualified yoga
instructors. Our classes are safe and true to the spirit of Yoga. However, not all
yoga instruction is appropriate for everyone. Everyone’s body is different and
our instructors may not be fully aware of your body’s levels of flexibility or
any injuries or areas of weakness you may have. We ask all students to take
responsibility not to over stretch or strain in any class. The teacher will
suggest modifications if they recognize that you are experiencing difficulty.
Please do not compromise the safety of your body and let the teachers know if
you need addition help. Welcome Mat
Family Yoga LLC cannot be held responsible for any injuries that occur in
these classes. Participation in yoga
classes includes, but is not limited to, participation in meditation
techniques, yogic breathing techniques, and performing various Yoga postures.
Yoga postures, or asana, are designed to exercise every part of the body -
stretching and toning the muscles and joints, the spine and the entire skeletal
system. They also work on the internal organs, glands and nerves. Yoga
incorporates sustained stretching to strengthen muscles and increase
flexibility. Yoga and physical exercise is an individual experience. I
understand that in yoga, and in any other exercise class, I will progress at my
own pace. If at any point I feel overexertion or fatigue, I will respect my own
body's limitations and I will rest before continuing yoga or any other
exercise. By signing my name below, I acknowledge that participation in Yoga
classes or any other exercise class exposes me to a possible risk of personal
injury. I am fully aware of this risk and hereby release Welcome Mat Family
Yoga LLC, or any other persons who may teach at Welcome Mat Family Yoga LLC, from any and all liability,
negligence, or other claims, arising from, or in any way connected, with my
participation in Yoga and any other exercise class.
My signature further acknowledges that I shall not now, or at any time in the future, bring any legal action against Welcome Mat Family Yoga LLC, or any other persons who may teach at Welcome Mat Family Yoga LLC, and that this waiver is binding on me, my heirs, my spouse, my children, my legal representatives, my successors and my assigns.
My signature verifies that I am physically fit to participate in Yoga classes, or any other exercise classes, and a licensed medical doctor has verified my physical condition for participation in this type of class. If I am pregnant, or become pregnant, or am post-natal, my signature verifies that I am participating in yoga, or any other exercise classes, with my doctor's full approval.
I realize that I am participating in yoga, or any other exercise classes, at my own risk.
Informed Consent and Waiver of Liability
I understand that Yoga and any other exercise program can be physically intensive, and I voluntarily assume the risk inherent in my participation in exercise classes at Welcome Mat Family Yoga LLC, including the risk of injury, accident, death, loss, cost or damage to my person or property. I release and indemnify Welcome Mat Family Yoga LLC, from, and against, any and all such claims and liabilities, including attorneys' fees.
I further attest that I am in sufficient physical health, and/or that I have consulted with a physician and I am able to undertake and engage in the physical movements and exercises in classes that I have chosen to take at Welcome Mat Family Yoga, LLC.
I assume responsibility to update Welcome Mat Family Yoga LLC of any changes in my medical condition that might affect my safety or participation in any classes at Welcome Mat Family Yoga LLC.
Printed Name: ___________________ Date: ______________________________
Signature of Participant or Legal Guardian (if under 18):_____________________
I, ________________________, give my permission to use my name, likeness, image, and/or appearance as such may be embodied in any pictures, photos, videos, digital images, and the like, taken or made on behalf of Welcome Mat Family Yoga LLC and Welcome Mat Family Yoga activities. I agree Welcome Mat Family Yoga has complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent the Welcome Mat Family Yoga mission. These uses include, but are not limited to illustrations, newsletters, exhibitions, videotapes, reprints, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation, etc. for the use of such pictures, etc., and hereby release Welcome Mat Family Yoga and its agents and assigns from any and all claims which arise out of or are in any way connected with such use.
I have read and understood this consent and release.
I give my consent to Welcome Mat Family Yoga LLC to use my name and likeness to promote their programs, and/or their activities.
I do not give my consent to Welcome Mat Family Yoga LLC to use my name and likeness to promote their programs, and/or their activities.