Informed Consent and Waiver of Liability for Healing Hart Wellness & Polliwog Kids Yoga and Mindfulness

Please sign waiver below prior to participation in any private, group or workplace yoga sessions with Healing Hart Wellness or Polliwog Kids Yoga. Waiver also required for all guests at a yoga birthday party, and for teachers in attendance at workshops/trainings.

Name *
Name
Name of Minor Child (If Applicable)
Name of Minor Child (If Applicable)
Phone Number *
Phone Number
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone Number *
Emergency Contact Phone Number
Informed Consent and Waiver of Liability *
Informed Consent and Waiver of Liability
I acknowledge that I understand that yoga is a physical activity and I am a voluntary participant. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I assume full responsibility for any and all risks, injuries or damages, which may incur through my participation or participation of my minor child(-ren), if applicable, in yoga or any other related instruction with BJ Hart, Courtney Hart or any other instructors of Healing Hart Wellness, LLC/Polliwog Kids Yoga. I affirm that I understand that it is my responsibility to consult with a physician prior to and regarding my participation, or the participation of my minor child(-ren), in any yoga session. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I agree to make the instructor aware of any medical conditions or physical limitations of myself, or my minor child(-ren) before any instruction occurs. I agree to follow all instructions and pay attention to my own body, discontinuing activity if I begin to experience discomfort or pain. I will also make sure that my minor child(-ren) understand(s) this information. 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 of myself, and my minor child(-ren) if applicable, is at my own risk. I knowingly, voluntarily and expressly waive any claim that I may have against BJ Hart, Courtney Hart, and any other instructors of Healing Hart Wellness, LLC/Polliwog Kids Yoga and any facility at which I, or my minor child(-ren) if applicable, attend a yoga session including its owners for any injury, death or damages that I may sustain as a result of participating in a yoga class, workshop, birthday party, or pre-registered yoga session, including loss that may be caused by the negligence of the released party. I release and discharge BJ Hart, Courtney Hart and Healing Hart Wellness, LLC/Polliwog Kids Yoga from any and all liability, claim, demand or action that I may have related to loss, theft or damage of any of my, or my minor child(-ren)'s if applicable, personal property while at a facility. 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 signature serves as complete and unconditional release of all liability to the greatest extent allowed by law. If signing for a minor child(-ren), I affirm that I am the parent or legal guardian for any minor child(-ren) listed above in this waiver. I understand that the entirety of this waiver also applies to my minor child(-ren) even where notation may have been left out in error.