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Home Phone Number

Cell Phone Number

What class will you be joining?

If no, how long have you been practicing and what type?

Please provide details of any injuries or limitations you have

Please keep me posted of any changes to your health and remember to listen to your body and only do what your body will allow

What interests you most about yoga/meditation? What are you hoping to gain?

Is there anything else you would like me to know?

Yoga & Meditation Consent Form

By providing my signature below, I confirm I have read and understood the statements below and the information provided above is true and correct to the best of my knowledge.

I understand that I must be mindful of my own limitations with respect to yoga and meditation

I understand as with all forms of exercise, the effects of yoga may not be noticeable immediately and the results are not guaranteed

I recognize that yoga may involve physical exertion

I acknowledge it is my responsibility to inform the instructor when I begin a class of any injury or other condition that might affect my ability to participate or if any injury occurs during the class

During a class if at anytime I feel that instructions or class activities present any risk of injury to me, or if I feel tired or otherwise unable to perform class activities I will inform the instructor and refrain from activities in question.

I understand it is my responsibility to consult with a physician prior to and regarding my participation in yoga and meditation

I agree to hold harmless and release from liability Julie Boyse and Journey 2 Balance and the location the class is being taught at for any condition or results known or unknown that may arise as a result of, or that I think could be attributed to, any movement that I have chosen to make and from any and all claims of malpractice, non-disclosure or lack of informed consent.

I grant Journey 2 Balance, it's representativs and employess the right to take photographs of me and my property in connection with the above-identified subject. I authorize Journey 2 Balance, it's assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Journey 2 Balance may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and web content.

Student Name

Date

By entering my name in this field, it is considered my online signature.

Thank you for your time in filling out the form

Journey 2 Balance

Inspiring true life balance

Health & Well-being form for Yoga & Meditation

Yoga & Meditation Consent Form