Waiver | Inner Essence Yoga

Medical History and Waiver

Please fill out the following form to the best of your ability.

First Name

Email Address

Last Name

Date of Birth

Have you been hospitalized in the last 12 months?

Yes

Are you currently experiencing a physical, mental or emotional condition, illness, or injury?

Yes

How did you hear about us? And, if you answered yes to any question above, please elaborate. What are your Yoga Therapy goals?

Emergency Contact Name & Phone:

Today's Date

I declare that the info I’ve provided is true & complete. I agree to the following statements: I understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I acknowledge that yoga is an exploration of a person’s physical and mental potential, and that my participation in yoga class can cause serious injury, property damage, or potential death. Undertaking a Yoga Therapy session necessitates a regular physical practice as well as breath work. I accept responsibility for my physical limitations, and personal safety. If I experience any pain or discomfort, I will listen to my body, adjust the posture, take a break, and ask for support from the Yoga Teacher. Yoga and Yoga Therapy are not substitutes for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. It is my responsibility to check with my healthcare practitioner as to whether or not the demands of Yoga are within my capabilities if a health condition exists. With a full understanding of the potential risks, I hereby assume the risks of participating in a yoga class or private Yoga Therapy Session. I affirm that I alone am responsible to decide whether to practice yoga. I hereby agree to irrevocably waive, release and discharge any claims and/or liabilities for death or personal injury or damages of any kind, except that which is the result of gross negligence and/or wanton misconduct of the persons or entities listed below, that I have now or hereafter may have against the following persons or entities: Nicole Simonich. I agree to not sue any of the persons or entities listed above for any of the claims or liabilities that I have waived, released or discharged herein. I indemnify and hold harmless the persons or entities mentioned above from any claims made or liabilities assessed against them as a result of my actions.

Thanks for submitting!

Mind Body Truth

Soulful Living Coach

and

...a Trauma Informed Integrative Approach to Healing.

Medical History and Waiver