Medical Questionnaire Release Waiver of Liability and Indemnity

Application, Medical Questionnaire, Release, Waiver of Liability and Indemnity Agreement

with 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 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 .

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    YES NO (Specify)

Hypoglycemia    YES NO

Malaria    YES NO (date)

Mononucleosis    YES NO (date)

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    YES NO (date)

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 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 , 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 agrees to the following:

1. I, do fully comprehend and assume all risks involved in participating in Yoga Training. I have been advised by , 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 . I do hereby remise, release, quitclaim, and forever discharge , 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 , 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 , or while engaging in physical conditioning exercises.

3. In consideration of being allowed to participate in said Yoga Training of , 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 , its employees or agents, administrators, successors and assigns from all acts of active or passive negligence on the part of , its employees or agents, administrators, successors and assigns.

4. I also agree to INDEMNIFY AND HOLD release , 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 .

If Client is under the age of eighteen (18), Parents or Guardians must also sign the following Agreement.

The undersigned , 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 , its employees or agents, administrators, successors and assigns harmless as set forth in said Agreement and join in all waivers and releases of hold , 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 .