Retreat Health Form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

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Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Do you have heart trouble? *

Y

N

Do you frequently have pain around your heart or chest? *

Y

N

Do you ever feel faint or have spells of severe dizziness? *

Y

N

Have you ever been told your blood pressure is too high or low? *

Y

N

Has your doctor ever told you that you have a bone or joint problem that might be made worse by exercise? *

Y

N

Do you have any other physical conditions which would require you to proceed with caution in an exercise program? *

Y

N

I hereby grant JEFFERSON GUZMAN YOGA the authority to photograph my appearance in a group photo at the conclusion of the retreat and to use the photograph on the JEFFERSON GUZMAN YOGA website: *

I agree

I disagree

Whether complimentary or paid, by participating in activities offered by JEFFERSON GUZMAN YOGA, in signing below, I HEREBY RELEASE AND FOREVER DISCHARGE JEFFERSON GUZMAN YOGA and its shareholders, directors, officers, agents, servants and employees and or their successors, heirs, assigns (the Releasees) of and from all actions, causes of action and exams or every kind or nature whatsoever, however caused arising out of, or in any way described below and notwithstanding that the name may have been contributed to or occasioned by the negligence of the RELEASEES or without limiting the generality of the foregoing. I also acknowledge and understand that a risk of personal injury may be involved in the exercise. I THEREFORE AGREE TO FOLLOW INSTRUCTIONS CAREFULLY. Yoga classes, workshops, intensives, and study groups include techniques and exercises for the development of strength, flexibility, endurance, stamina, relaxation, and breath awareness. Some classes may include the use of equipment in support of the above techniques (mat, belts, pillows, bricks, benches etc.). I agree that JEFFERSON GUZMAN YOGA is in no way responsible for the safekeeping of my personal belongings at any time. I understand that JEFFERSON GUZMAN YOGA classes may be physically strenuous and I voluntarily participate in them with the full knowledge that there is a risk of personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise. *

By checking here, I am consenting to the use of my electronic signature in lieu of an original signature on paper. I understand I have the right to request to sign a paper copy instead. By checking here I am waiving that right.

Date *

MM

DD

YYYY