Health Form

ABOUT YOU

Name *
Name
Birthday
Birthday
Phone
Phone
Address
Address
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Number *
Emergency Contact Number

Help me serve you better

(If the answer is no please skip to question 4)
Do you suffer from any of the following health issues? Check where applicable.
Are you ok with use of the following?
I understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor. I will continue to breathe smoothly. I assume full responsibility for any and all damages, which may incur through participation.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 hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Wellness By Roma LLC and it's instructors.
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 Print name below represents my signature and serves as complete and unconditional release of all liability to the greatest extent allowed by law in the State of New Jersey.
Date
Date