Emerge Health Waiver

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Please fill out prior to attending any Emerge Movement classes, workshops, or retreats.

Full name:

Mailing Address:

Email address:

phone number:

Emergency Contact name & phone number:

Please be aware of your body. Let Emerge Movement know what medical problems you may have, including but not limited to; heart trouble, Diabetes, Hypoglycemia, Asthma, lower back pain, high or low blood pressure. If you have had a recent surgery, or are pregnant, you should not participate without written consent from your doctor. Do you have any medical problems Emerge Movement should be informed about?

Yes

If yes, please explain below.

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I the UNDERSIGNED, acknowledge that I should inform the instructor of any physical limitations, problems or conditions that would adversely affect my ability to participate in any strenuous exercise without further injury. I further agree to inform the instructor of any injury or unusual pain suffered by me during or following class. I understand that in any program of strenuous exercise, there is some risk of injury, despite the best efforts of the professional instructors and I am willing to assume all risks.

Please initial below:

Therefore, I hereby waive and release (for myself, my heirs, my executors, and administrators), Emerge Movement and their employees, from all claims, liabilities, expenses, or judgements arising out of my participation in Emerge Movement classes, workshops, and retreats.

I have read the above, I understand and agree.

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And date:

YYYY

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