Student Yoga Participation Form

STUDENT YOGA PARTICIPATION FORM

School/Organization Name:

STUDENT INFORMATION

Date of Birth:    Student ID:    Grade/Program:

PARENT / GUARDIAN CONTACT (IF STUDENT IS A MINOR)

Relationship to Student:    Primary Phone:    Email:

PROGRAM DETAILS

Instructor:    Location:

Program Start Date:

MEDICAL INFORMATION & EMERGENCY CONTACT

Emergency Contact Phone:    Relationship:

Physician Phone:    Insurance Provider:    Policy / ID #:

CONSENT, RELEASE, AND MEDICAL AUTHORIZATION

Assumption of Risk: I acknowledge that participation in yoga and related physical activities involves inherent risks, including but not limited to strains, sprains, aggravation of pre-existing conditions, or more serious injury. I affirm that the student is physically able to participate in yoga activities unless specifically noted in the medical information above. By signing, I knowingly and voluntarily assume all risks associated with participation.

Release and Indemnification: To the fullest extent permitted by law, I release, waive, discharge, and covenant not to sue the School/Organization, its officers, instructors, employees, volunteers, and agents from any and all liability, claims, demands, actions, or causes of action arising out of or related to any loss, damage, or injury sustained by the student while participating in the program, except for gross negligence or willful misconduct. I agree to indemnify and hold harmless the School/Organization for any claims brought by or on behalf of the student.

Emergency Medical Treatment Authorization: In the event of a medical emergency, if I cannot be reached, I authorize program personnel to obtain necessary medical treatment for the student, including but not limited to transport to a medical facility, administration of first aid, and referral to emergency medical personnel. I understand that reasonable efforts will be made to contact the parent/guardian or emergency contact prior to treatment when practicable.

Certification of Truth: I certify under penalty of perjury that the information provided on this form is complete and accurate to the best of my knowledge.

SPECIAL ACCOMMODATIONS / ADDITIONAL INSTRUCTIONS

ACKNOWLEDGMENT

By signing below, I affirm that I am the parent or legal guardian of the named student, or the student if age 18 or older, and that I have the authority to execute this consent and release. I understand that this form constitutes a binding legal agreement.

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