New Student Info + Waiver

First Name*

Last Name*

Today's Date [mm/dd/yy]*

Your City*

Your State*

Your Email*

Your Phone*

Your Birthdate [mm/dd/yy]*

Emergency Contact*

Emergency Contact Phone*

How did you find Moondance Wellness Coaching?*

Did anyone refer you? Please list them here so I can thank them!*

Do you have any physical limitations/injuries/illness that may affect your yoga practice?

Agreement of Release and Waiver of Liability

I understand that yoga includes physical movements, and as is the case with any physical activity, the risk of serious injury is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, adjust the posture and ask for support from the teacher.

It is my responsibility to consult with a physician prior to my participation in the yoga class. I represent and warrant that I have no medical condition that would prevent my full participation in the yoga class. I am aware I may be physically adjusted. I agree to take full responsibility for any risks, loss, claim, injury, damage or liability, known or unknown, which I might incur as a result of participating in the program. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I affirm that I alone assume the risk of yoga practice, and hereby release Angela Kittock and Moondance Wellness Coaching, LLC from any liability claims. While engaging in any class or activity operated, organized, arranged or sponsored by Moondance Wellness Coaching, LLC, either on or off their premises, I shall do so at my own risk, and hold Angela Kittock and Moondance Wellness Coaching, LLC forever harmless from any and all loss, claim, injury, damage, or liability sustained or incurred by me.

I have read the release and waiver of liability and fully understand its consent. I voluntarily agree to the terms and conditions stated above.

I agree to the terms stated above. Or I consent to the terms on behalf of a participant under 18 for whom I am a legal guardian.

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