Retreat Waiver | stacy-levy-yoga

Stacy Levy Yoga Retreat
Waiver & Release Form

First Name

Last Name

Street Address

City

Region/State/Province

Postal / Zip code

Date of Birth

Phone

How did you hear about Stacy?

Have you practiced yoga before? If yes, how long/often?

Do you have any physical problems or limitations (surgery, illness, injury, etc.)?

Please read carefully:

Acknowledgement/Assumption of Risk of Injury

I have fully informed myself of all details of taking yoga with Stacy Levy Yoga and have received satisfactory answers to all questions I have concerning the yoga classes and the risks inherent in the program. I acknowledge that there are certain risks of injury, damage or loss associated with participation in yoga. I agree to assume the full risk of any injury, loss or damages regardless of severity, which I may sustain as a result of participating in the yoga classes.

Waiver and Release of Claims for Injury/Permission to Treat

I hereby agree to, and do waive, release and relinquish all claims of every kind, known and unknown, present and future, that I may have against Stacy Levy Yoga, and the hosting facilities, arising out of, connected with, or in any way related to, the program and my participation therein.
In the event of an emergency, I authorize Stacy Levy Yoga, and/or the hosting facility to secure from any licensed hospital, physician or medical personnel any treatment deemed necessary for my immediate care and I agree I will be responsible for payment of any and all medical services required.

Indemnity and Defense

I further agree to indemnify and to hold harmless and defend Stacy Levy Yoga, and the hosting facility from any and all claims of every kind, known and unknown, present and future, that I may have arising out of, connected with, or in any way related to the yoga classes and my participation therein.

Your Signature

Select a date

Stacy Levy Yoga Retreat Waiver & Release Form

Stacy Levy Yoga Retreat
Waiver & Release Form