Southern Pines Yoga Co. Waiver

Southern Pines Yoga Co.

Information, Waiver and Release Form

Name: _______________________________________________________________________________

Address:  ___________________City___________________State___________________Zip_________

E-Mail: _______________________________________________________________________________

Phone #: _____________________________________________________________________________

Emergency Contact #1: __________________________________________________________________

Emergency Contact #2: __________________________________________________________________

Birthday: _____________________________________________________________________________

Medical Conditions: ____________________________________________________________________

Any injuries we should know about?  _______________________________________________________

How did you hear about the studio?  _______________________________________________________

 

The undersigned, in consideration of the participant’s being allowed to participate in Yoga classes (referred to as the “classes”) provided by JIBGIRL, LLC, dba Southern Pines Yoga Co., and its instructors does release JIBGIRL, LLC, dba Southern Pines Yoga Co., Michelle A. Kaiser, and Income Properties of Raleigh and Cail Realty, and their employees, agents,  members and their independent contractors from any claims or liability arising from participant’s participation in or presence at the classes or at the premises where the classes occur.

 

The undersigned is specifically aware of and recognizes that the participation in and presence at the classes and in the premises presents the possibility of falls, injuries, and reaction to the regime called for by the classes, and the undersigned assumes the risks associated with such.

 

The undersigned warrants that he/she has investigated the nature and characteristics of the classes (including the fact that theymay involve prolonged stretching in a highly heated setting), the premises, and the facilities that he/she will be exposed to or in contact with during his/her participation and has determined that they present no danger or risk that he/she is unwilling or unable to assume.

 

The undersigned warrants that he/she has either been cleared by his/her physician to participation the classes or has chosen not to seek such clearance and has no conditions that would be aggravated by or would cause risk or harm as a result of participation or of using the facilities or premises.  The undersigned further agrees that he/she will no longer participate if he/she becomes aware of any condition that would cause risk or harm or that would be aggravated by participation.

 

The undersigned acknowledges that no one associated with the classes is providing medical treatment or advice to him/her and he/she will not regard any action or communication during participation as medical treatment or advice.

 

The undersigned further indemnifies and holds harmless by JIBGIRL, LLC, dba Southern Pines Yoga Co., Michelle A. Kaiser, and its instructors does release JIBGIRL, LLC, dba Southern Pines Yoga Co., Michelle A. Kaiser, and Income Properties of Raleigh and Cail Realty, and any other independent contractors and Income Properties of Raleigh and Cail Realty, and any of their employees, agents, or members from any claims or liabilities arising from the participant’s participation or presence, including injuries or damage to himself/herself or others.

 

______________________________

Printed Name

______________________________    ________________________

Participant’s Signature                           Date

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Contact Us

(910) 246-0065 contact@southernpinesyoga.com

Location

The Shops of Southern Pines *Next to The Fresh Market 169 Beverly Lane Southern Pines, NC 28387