Unity Yoga Center Informed Consent and Emergency Information

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Email *

Full Name: *

Phone Number:

Date of Birth: *

YYYY

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone Number: *

I, the undersigned client, understand that involvement in these sessions may include physical, emotional, psychological, and spiritual activity. As such, there is inherent risk. I agree that I am responsible for assessing the risk and making safe empowered choices for myself. *

Yes

I, the undersigned client, agree to assume the risk and responsiblitiy for any injuries or damages arising out of my participation in all sessions with Dayna Pinkerton LLC, Unity Yoga Center. Furthermore, I accept complete responsibility for my health and well-being in this voluntary program and understand that no responsibility is assumed by Dayna Pinkerton, LLC or guest teachers. I attest that I am physically fit and I have no medical conditions or injuries which would prevent my full participation in yoga therapy classes. I, my heirs or legal representatives, forever release, waive, discharge, and covenant negligence for any injury, condition, or death, which arises, is caused by or is aggravated by reason of my participation in yoga classes with Dayna Pinkerton, LLC. *

Yes

Do you currently have any injuries or concerns? *

Today's Date: *

YYYY

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