GALERIE WELLNESS
122 W. College Street Kent, Ohio 44240
galeriewellnesskent.com


Waiver of Liability / Informed Consent
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FULL NAME: *
PHONE: *
EMAIL:  *
ADDRESS:  *
DOB:  *
SOCIAL MEDIA USERNAME: 
EMERGENCY CONTACT NAME:  *
EMERGENCY CONTACT PHONE: 
*
HOW DID YOU HEAR ABOUT GALERIE WELLNESS: 
REFERRED BY MEMBER: 
Do you have any physical limitations that could be aggravated by exercise? (example: back, hip, knee, neck, shoulder pain or problems)  YES   or   NO
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IF YES, PLEASE EXPLAIN:

Waiver of Liability / Informed Consent

I understand that the class I have enrolled in includes physical movement and activity. I have voluntarily enrolled in a fitness class, yoga, meditation, workshop, or service offered by Galerie Wellness and/or Garage 108. As with any physical activity, the risk of injury is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body and discontinue such activity or ask for support from the instructor. I have consulted with my healthcare professional or provider and have been cleared to participate in these activities. If I am pregnant or become pregnant, my signature verifies that my physician has approved my participation. I will keep in communication with my instructor regarding my unique needs if there are any. I will ask questions when appropriate and follow instructions carefully. I assume full responsibility for any and all damages that may incur through participation. I will take full responsibility for moderating my activities in order to honor my well-being, be aware of my own limitations and strengths. I hereby release Galerie Wellness and/or Garage 108, its owners, officers, employees, and my instructors from any liability now or in the future for any injury, illness, or damage occurring during and after my participation in the class, workout, or service. I understand that all the information presented is for educational purposes only and is not intended as medial or mental health advice, diagnosis, or treatment. I consent to my image or likeness can be used in-full or in-part of marketing online, social media, ads, or otherwise for promotion of the studio. I have read and fully understand and agree to the above terms of this agreement and release of wavier of liability. I recognize and consent that all sales are final and the company does not offer any money-back guarantees or refund for purchases. I am signing this agreement voluntarily and recognize that my signature serves as a complete and unconditional release of liability of the greatest extent allowed by law in the State of Ohio.

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By printing my full name signature this is an electronic version and collection of my signature.
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DATE: *
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Galerie Wellness
122 W. College Street Kent, OH 44240

 galeriewellnesskent.com
 

Purchase classes or punch card via https://galeriewellnesskent.com/shop


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