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Yoga Waiver & Release
First Name
Last Name
Date of Birth
Phone
Email
Do you have a doctor’s permit to participate in intense physical activities?
No
Yes
Emergency Contact Name
Emergency Contact Phone
Please describe your previous yoga and/or fitness experience:
I am participating in the Power Yoga Vinyasa Class/Workshop, offered by Kirsten Ferguson or any substitute yoga instructor, during which I will receive information and instruction about yoga and health.
I recognize that yoga may require some physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of and accept the risks and hazards involved. In consideration of being permitted to participate in the Power Yoga Class or Workshop, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the program. I am responsible for modifying the practice to meet my physical abilities.
I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Power Yoga class or Workshop. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. By signing, I affirm that a licensed physician has verified my good health and physical condition to participate in such a fitness program. In addition, I will make the instructor aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician's approval to participate. I also affirm that I alone am responsible to decide whether to practice yoga and participation is at my own risk.
I understand that, although Kirsten Ferguson is a chiropractic doctor, the information and instruction received during my participation in this program is not to be construed as medical advice or diagnosis. I further agree that a medical opinion from Dr. Ferguson within her scope of practice, is only available directly through a complete examination in her office at Fern Creek Chiropractic Center.
I represent and warrant that I am physically fit and I have no medical condition which would prevent my full participation in the Power Yoga Class/Workshop.
In further consideration of being permitted to participate in the Power Yoga Class/Workshop, I knowingly, voluntarily and expressly waive any claim I may have against Kirsten Ferguson or any substitute yoga instructor for any injury or damages that I may sustain as a result of participating in the program. I, my heirs or legal representatives, forever release, waive, discharge and covenant negligence or other acts.
I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. I am signing this agreement voluntarily and recognize that my signature serves as complete and unconditional release of all liability to the greatest extent allowed by law
I irrevocably grant Kirsten Ferguson, Fern Creek Chiropractic, VitalityDoc the right to use my name, likeness, photos, reproduction or testimonials for promotional purposes.
I declare that the info I’ve provided is accurate & complete
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Is registrant under 18 years of age?
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Yes
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HOME CARE
BLOG
SHOPPING
Package Pricing
FootLevelers Custom Orthotics
VitalityDoc Oils
Chiroflow Pillow
BioPosture Mattress
Crossover Symmetry
Gift Card
Amazon Recommended Products
PROGRAMS
Musculoskeletal (MSK) Pain Solutions
Pillars of GI Health
Cardiometabolic (CM) Vitals
Wellmatrix - Optimize Health
Immune Foundations
SOS Stress Recovery
Detoxification
Online Programs
Yoga
BENEFITS
SERVICES
Chiropractic
Decompression Traction
Cold Laser
Dry Needling
Functional Health
Labs
ABOUT
Meet The Team
Office Hours
Why Choose Us!
Insurance & Financial Policies
Contact Us
REVIEWS
BOOK NOW
PAPERWORK
More
Use tab to navigate through the menu items.
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