Kids Yoga Waiver

Kids Yoga with Emily Waiver Form

Today’s Date: ___________________ Child’s Full Name: ________________________________ Age: _____________

Date of Birth: _________________ Boy ______ Girl _____ Parent/Guardian Full Name: _____________________________________________

Address: _________________________________________ Apt. ______________ City: ___________________ State: __________ Zip Code: _________________

Mobile: _________________________ Home: _____________________________ Work: __________________________ Caregiver: __________________________ Email: ________________________________ Emergency Contact and Number: _________________________________________ Doctor Name and Number: ______________________________________________

Please list all known allergies, physical limitations, concerns and goals: ____________________________________________________________________ ____________________________________________________________________

How did you hear about us? _____________________________________________ Class _________________________ Package _____________ Drop-in _______ Liability Disclaimer &

Notices: please read carefully as this is a legally binding document:

I individually and as parent and/or guardian of the minor child identified above hereby acknowledge the following notices and grant to Kids Yoga with Emily the following release from liability: A​. I acknowledge and fully understand that I, or my child, will be engaging in physical activities that may involve some risk of injury. I acknowledge and have been advised that it is my responsibility to consult with my or my child’s physician with respect to any past or present injury, illness, health problem or any other condition or medication that may affect my or my child’s participation. I assume the foregoing risks and accept full personal responsibility for any personal injuries sustained by my child which might incur as a result or participating in this program and discharge and hold harmless Kids Yoga with Emily, its owners, directors, members, employees and agents from any claim, cause of action or liability for damages arising from any personal injury to my child or other persons or property caused by myself or my child’s participation in the Kids Yoga with Emily program. B​. I clearly understand that cancellations are to be made an hour prior to the class time for a full refund. I agree and and understand that if I miss class(es) during a session in which I am currently enrolled, there will be only (1) makeup class held at the end of the session. C​. I agree / disagree to give Kids Yoga with Emily permission to use photographs of myself or my child for any Kids Yoga with Emily promotional materials. I understand that my child will not be identified by name, nor will any compensation be extended for such use.

Parent /Guardian Signature _____________________________________________