Yoga with Emma Waiver Form SECTION I: PERSONAL INFORMATION Name: Address: Phone: Email: Emergency Contact Name: Emergency Contact Phone: Relationship to you: SECTION II: RISK ASSESSMENT Heart Disease: YesNo Shortness of Breath or Chest Pain: YesNo Inhaler (if “yes”, please bring it to every class): YesNo High/LowBlood Pressure: YesNo If yes, Blood Pressure levels: High Cholesterol Level: YesNo Significant Bone/Joint/Muscle Pain: YesNoIf yes, location Back Pain: YesNo Cigarette Smoking: YesNoIf yes, amount Diabetes: YesNo Insulin Dependent? YesNo Any other? Please explain: Are you currently, or could you be pregnant? YesNoIf yes, how far along? Have you been pregnant recently? YesNoIf yes, how long ago? If yes, Type of birth Have you been medically cleared to exercise? YesNo Are you currently exercising 3 or more times a week? YesNoIf yes, Activity or Excercise Are you currently taking any medication(s)? YesNoThis disclaimer was created using an SEQ Legaltemplate.SECTION III: AGREEMENT1. Introduction This disclaimer governs all of our classes, and we will ask you to sign it prior to taking part in any Yoga with Emma class You acknowledge that all exercise involves a risk of personal injury, including a small risk of serious injury or death, and agree to take responsibility for your health and well-being in relation to our classes.2. Health and medical conditions.You agree that you have filled out the above risk assessment to the best of your knowledge and ability, and have obtained your doctor’s approval, where required, prior to participating in our classes.Where doctors’ approvals are required, this must be in writing, and copies must be provided to us upon request.You must inform us as soon as possible if:•You suffer from any new injury, illness, or other medical condition •You feel any pain or discomfortduring any class •You feel that any exercise included in any class would be unsafe or uncomfortable for youWe may, in our sole discretion, prohibit you from participating in a class, and you agree to comply with all of our instructions in relation to our classes.3. Limitations and exclusions of liabilityThe limitations and exclusions of liability set out in this section and elsewhere in this disclaimer: are subject to section 4 below; and govern all liabilities arising under the disclaimer or in relation to our classes, including liabilities arising in contract, in tort (including negligence) and for breach of statutory duty.We will not be liable to you in respect of any personal injury (including without limitation serious injury or death) that you may suffer or sustain directly or indirectly as a result of attending our classes. Nor will we be liable to you in respect of any other losses arising as a result of any such personal injury.We will not be liable to you in respect of any of your personal property that is lost, stolen or damaged before, during or after a class.We will not be liable to you in respect of any losses arising out of any event or events beyond our reasonable control.We will not be liable to you in respect of any business losses, including (without limitation) loss of or damage to profits, income, revenue, use, production, anticipated savings, business, contracts, commercial opportunities or goodwill.We will not be liable to you in respect of any special, indirect or consequential loss or damage.4. ExceptionsNothing in this disclaimer shall: limit or exclude our liability for death or personal injury resulting from negligence; limit or exclude our liability for fraud or fraudulent misrepresentation; limit any of our liabilities in any way that is not permitted under applicable law; or exclude any of our liabilities that may not be excluded under applicable law.5. SeverabilityIf a section of this disclaimer is determined by any court or other competent authority to be unlawful and/or unenforceable, the other sections of this disclaimer continue in effect. If any unlawful and/or unenforceable section would be lawful or enforceable if part of it were deleted, that part will be deemed to be deleted, and the rest of the section will continue in effect.6. Law and jurisdictionThis disclaimer shall be governed by and construed in accordance with English law, and any disputes relating to this disclaimer or our yoga classes will be subject to the exclusive jurisdiction of the courts of England and Wales.7. Our detailsIn this disclaimer, "we" means (and "us" and "our" refer to) Yoga with Emma.The limitations and exclusions of liability in this disclaimer protect our instructors as well as protecting us.I accept and agree to the terms and provisions contained in this agreement.