Thanks for joining us for the weekly live, online Cancer Wellness yoga class.  Our lawyer and insurance company won’t let you participate if you have not sent in the waiver below prior to your first class.  Please copy and paste the form below and return it to me with your responses via email at karagalvin@gmail.com.  If you have any questions, call or text me at (303) 669-7284.

Questionnaire & Registration Form for Cancer Wellness Yoga   

Name:

Today’s Date:

Phone:

Address:

City:

State:

Zip:

Email address:

DOB:

Emergency Contact Name:

Emergency Contact Phone:

Has your doctor given you permission to return to physical exercise?

Are you currently in treatment?

Are all of your surgical wounds fully healed?

Are you able to do the following with relative ease and comfort? (Please answer yes/no)

Stand:

Sit:

Lie on your back:

Lie on your stomach:

Lie on your right side:

Lie on your left side:

Go up a flight of stairs with ease?

Have you practiced yoga before?  If so please describe:

What are your goals for participating in this class?

Do you have any special concerns about participating in this class?

I understand that Kara Galvin of Namaste Industries, LLC has the right to refuse my registration for this class for safety reasons ____________ (Please initial)

I _________________________________(print name) understand that yoga includes physical movements as well as an opportunity for relaxation, stress reduction and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, adjust or skip the posture and ask for support from the teacher. I will continue to breathe smoothly.

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 affirm that I alone am responsible to decide whether to practice yoga.  I affirm that my platelet count is at least 20,000 and all surgical incisions on my body have healed.  I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against Namaste Industries, its Instructors and staff and the facility where class is held.

Virtual Signature of student:

Date: