Waiver/Medical Release Form

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Waiver & Medical Release Form for With Intentions Holistic Studio, 1700 Main St, Ste 101, Lake Como, NJ 07719

Email *

First Name *

Last Name *

Preferred Pronoun

Email *

Phone number *

Date of Birth *

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Occupation

Address *

Allergies/Medical History you wish you disclose

Emergency Contact (Name, relationship, phone number, address) *

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Yes

Waiver/Release: My participation in this class/workshop/event/session is voluntary and at my own risk. I take responsibility for any activity that I choose to participate in at With Intentions Holistic Studio LLC. I hereby release respective owners, instructors/facilitators, and assigns from any liability for claims, demands, injuries, deaths, actions, or causes of actions to my person or property arising out of or connected with the use of any services, equipment, or facilities provided by With Intentions Holistic Studio LLC or any instructor/facilitator. Furthermore, I understand the activities may involve physical activity or the use of tools/materials and risk of bodily injury and I accept full responsibility for any activities I engage in at With Intentions Holistic Studio LLC. I have read with a full, definite, and clear understanding of the foregoing provisions and freely enter into the agreement of the waiver/release. *

Yes, yes I have read and freely enter into the agreement of the waiver/release.

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