Fill and Sign the Application Medical Questionnaire Release Waiver of Liability and Indemnity Form

Application, Medical Questionnaire, Release, Waiver of Liability and Indemnity Agreement with _______________________ (Name of Yoga Organization) to Study Yoga Full Name ______________________________________________________ Date of Birth _____________ Street Address _______________________________________________ City __________________________________________________ State____________ Zip______________________ Home Phone #__________________________ Cell Phone #__________________________ Email_____________________________________________ I understand that it is my responsibility to consult with a physician prior to and regarding my participating in the Yoga Classes, Health Programs or Workshops with ______________________ (Name of Yoga Organization) , and to receive prior approval to participate. I represent and warrant that I am physically fit and I have no medical condition or injury, which would prevent my full participation in the Yoga Classes, Health Program and Workshops of _____________________ (Name of Yoga Organization) . . Personal Health History Have you had any of the following? Respond with a “Y” if yes or a “N” if no in the space indicated. Please answer all questions. Do you have any allergies? [ ] YES [ ] NO If yes, please specify:____________________________________________________________________________________________________________________ Medications: Are you receiving allergy medication [ ] YES [ ] NO If yes, please specify: ________________________________________________________ ________________________________________________________ Do you take any of the following: Aspirin [ ] YES [ ] NO  Sulfa Drugs [ ] YES [ ] NO  Penicillin [ ] YES [ ] NO  Other [ ] YES [ ] NO (Please List Below)  ______________________________  ______________________________  ______________________________ Do you have any of the following conditions: Back Problems [ ] YES [ ] NO  Blood Clot/Phlebitis [ ] YES [ ] NO  Ear, Nose and Throat Trouble [ ] YES [ ] NO  Eye Trouble [ ] YES [ ] NO  Head Injury with Unconsciousness [ ] YES [ ] NO  Hospitalizations/Surgery (specify) [ ] YES [ ] NO  Hypoglycemia [ ] YES [ ] NO  Malaria (date) [ ] YES [ ] NO  Mononucleosis (date) [ ] YES [ ] NO  Pregnancy [ ] YES [ ] NO  Recurrent Bladder Infections [ ] YES [ ] NO  Recurrent Diarrhea [ ] YES [ ] NO  Rheumatic Fever [ ] YES [ ] NO  Sexually Transmitted Diseases (STDs) [ ] YES [ ] NO  Skin Diseases (acne, eczema, psoriasis) [ ] YES [ ] NO  Strep Throat [ ] YES [ ] NO  TMJ (jaw problems) [ ] YES [ ] NO  Transfusions (date) [ ] YES [ ] NO  Varicose Veins [ ] YES [ ] NO Alcohol/Drug Dependency [ ] YES [ ] NO  Anemia/Blood Disease [ ] YES [ ] NO  Anxiety [ ] YES [ ] NO  Arthritis [ ] YES [ ] NO  Asthma [ ] YES [ ] NO  Bulimia [ ] YES [ ] NO  Cancer, Cyst, Tumor [ ] YES [ ] NO  Diabetes [ ] YES [ ] NO  Depression [ ] YES [ ] NO  Epilepsy, Seizures [ ] YES [ ] NO  Gallbladder Trouble [ ] YES [ ] NO  Heart Murmur/Disease [ ] YES [ ] NO  High Blood Pressure [ ] YES [ ] NO  Kidney Disease/Infections [ ] YES [ ] NO  Liver Disease, Jaundice [ ] YES [ ] NO  Migraines [ ] YES [ ] NO  Obesity [ ] YES [ ] NO  Peptic Ulcer Disease [ ] YES [ ] NO  Psychological Problems [ ] YES [ ] NO  Thyroid Disease [ ] YES [ ] NO  Tuberculosis [ ] YES [ ] NO  Other Chronic Conditions [ ] YES [ ] NO (Please List Below)  ________________________________  ________________________________  __________________________________ I understand that it is my continuing responsibility to inform the instructor(s) at ______________________ (Name of Yoga Organization) of any previous medical conditions, injuries or surgeries prior to my first class and at such other times as I acquire information as to same. Have you practiced yoga before this class? [ ] YES [ ] NO If so, what style do you mostly practice? _______________________________ For and in consideration of being allowed to receive Yoga Training from _____________________ (Name of Yoga Organization) , and the mutual covenants contained in this Agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the undersigned ____________________ (Name of Client) agrees to the following: 1. I, _____________________ (Name of Client), do fully comprehend and assume all risks involved in participating in Yoga Training. I have been advised by _________________________ (Name of Yoga Organization), to consult my physician prior to my participation in Yoga Training to insure that I am physically able to engage in strenuous physical activity. 2. Being fully cognizant, and assuming all risks involved in the Yoga Training from _______________________ (Name of Yoga Organization) . I do hereby remise, release, quitclaim, and forever discharge ________________________ (Name of Yoga Organization) , its employees or agents, administrators, successors and assigns, of and from any and all manner of actions, suits, damages, judgments, executions, claims, or demands whatsoever in law or equity, or otherwise, against _______________________ (Name of Yoga Organization) , its employees or agents, administrators, successors and assigns, which I, my heirs, executors, or administrators hereafter can, shall or may have, for, upon or by reason of any injury that I may sustain or incur while participating in the Yoga Training of _____________________________ (Name of Yoga Organization) , or while engaging in physical conditioning exercises. 3. In consideration of being allowed to participate in said Yoga Training of _________________________ (Name of Yoga Organization), I do hereby assume all risks of my involvement and do covenant and agree not to bring legal action for damages should I sustain any injury, and do further release _________________________ (Name of Yoga Organization), its employees or agents, administrators, successors and assigns from all acts of active or passive negligence on the part of _____________________________ (Name of Yoga Organization) , its employees or agents, administrators, successors and assigns. 4. I also agree to INDEMNIFY AND HOLD release ____________________ (Name of Yoga Organization) , its employees or agents, administrators, successors and assigns harmless from any and all claims, actions, suits, procedures, costs, expenses, damages, and liabilities, including attorney’s fess brought as a result of my involvement in said Yoga Training and to reimburse them for any such expenses incurred. Witness my signature this ________________ (date). ____________________________ (Printed Name of Client) ____________________________ (Signature of Client) ____________________________ (Printed Name of Witness)____________________________ (Signature of Witness) If Client is under the age of eighteen (18), Parents or Guardians must also sign the following Agreement. The undersigned ____________________________________ (Names of Parents or Guardians) , declare that we are the Parents or Legal Guardians of the above named Client. In such capacity as Parents or Legal Guardians, we acknowledge that we have carefully read this Agreement and we do hereby assume all responsibilities and obligations of Client as set for therein and do specifically agree to indemnify and hold ___________________________ (Name of Yoga Organization), its employees or agents, administrators, successors and assigns harmless as set forth in said Agreement and join in all waivers and releases of hold __________________________ (Name of Yoga Organization) , its employees or agents, administrators, successors and assigns as set forth therein . CONSENT AS TO MEDICAL CARE In addition, in the event of an emergency or non-emergency situation requiring medical treatment, the undersigned Parents or Legal Guardians hereby grant permission for any and all medical and/or dental attention to be administered to Client, in the event of an accidental injury or illness. This permission includes, but is not limited to, the administration of first aid, the use of an ambulance, and the administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel. The undersigned request that we be contacted as soon as possible in the case such medical care is necessary or appears to be necessary. WITNESS our signatures as of the ____day of _____________, 20_____. ____________________________ (Printed Name of Parent or Guardian)____________________________ (Signature of Parent or Guardian) _______________________________ (Printed Name of Parent or Guardian)_______________________________ (Signature of Parent or Guardian) ____________________________ (Printed Name of Witness)____________________________ (Signature of Witness)