Moksha Yoga Minneapolis Waiver Form

  • To complete the WAIVER process, please fill in the following two forms to complete your waiver form online 
  • Both are required
  • Once You Are Done PURCHASE your $40 INTRO MONTH at the end of the Waiver Form
  • You will only be able to purchase this pass once

Client Profile Agreement of Release and Waiver
first name:
last name:
email address:
phone number:
address:
birthday:
How did you learn about us? (Check all that apply)
Google Search   Drive By
Magazine   Newspaper
Poster   Sign
Yellow Pages   Radio
Television   Postcard
Another Studio - Where?
  Promotional Event - What?
Referral by Doctor/Therapist - Whom?
  Friend - Whom?
Other
   
If you are a student, what school do you attend?
What other sports & activities do you participate in?
AWARENESS OF RISKS

. I acknowledge that the instruction offered by Moksha Yoga Minneapolis* is limited to that of instruction in basic yoga and fitness training.

. I acknowledge that there are risks associated with participation in the activities and programs offered or sponsored by Moksha Yoga Minneapolis. I have informed myself and understand the risks associated with my participation in these activities and programs and (where applicable) my use of the facilities, including the risk of personal injury, and I freely accept these risks.

. I understand that I am free to withdraw from or reduce my participation in the activities and programs offered or sponsored by Moksha Yoga Minneapolis at any time.

. I am not aware of any medical condition that would affect my ability to participate in the activities and programs offered or sponsored by Moksha Yoga Minneapolis. If I have any concerns about my medical condition. I will consult with my physician before participating in the activities and programs offered or sponsored by Moksha Yoga Minneapolis.

 

Are you currently experiencing any of the following conditions?
Asthma   High blood pressure
Heart/Circulatory Problems   Diabetes
Dizzy spells/Fainting   Epilepsy/Seizures
Pregnancy   Low blood pressure
Neck/Back/Spine injury - Specify:
  Muscular injury - Specify:
Joint injury (ankle, knee, hip, elbow, shoulder) - Specify:
  Recent surgery - Specify:
Other medical condition, injury or disability - Specify:
   

Are there any other injuries or ailments that the instructor should know about?

Are you currently taking medication or do you have any serious allergies that should be made known to the medical personnel in case of an emergency?
RELEASE AND WAIVER.

  • In consideration of participating in health or fitness club activities, and for other good and valuable consideration, I hereby agree to release and discharge from liability arising from negligence Moksha Yoga Minneapolis LLC and its owners, directors, officers employees, agents, volunteers, participants, and all other persons or entities acting for them (hereinafter collectively referred to as “Releasees”), on behalf of myself and my children, parents, heirs, assigns, personal representative and estate, and also agree as follows: 
  • I acknowledge that health or fitness club activities involve known and unanticipated risks which could result in physical or emotional injury, paralysis or permanent disability, death, and property damage.  Risks include, but are not limited to, musculoskeletal injuries, broken bones, and/or overuse injuries, injuries caused by equipment that  breaks or otherwise fails; death as a result of drowning or brain damage caused by near drowning; medical conditions  resulting from physical activity; and damaged clothing or other property.  I understand such risks simply cannot be  eliminated, despite the use of safety equipment, without jeopardizing the essential qualities of the activity. 
  • I expressly accept and assume all of the risks inherent in this activity or that might have been caused by the  negligence of the Releasees.  My participation in this activity is purely voluntary and I elect to participate despite the  risks.  In addition, if at any time I believe that event conditions are unsafe or that I am unable to participate due to physical or medical conditions, then I will immediately discontinue participation. 
  • I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Releasees from any and all claims, demands, or causes of action which are in any way connected with my participation in this activity, or my use  of their equipment or facilities, arising from negligence.  This release does not apply to claims arising from intentional conduct.  Should Releasees or anyone acting on their behalf be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs. 
  • I represent that I have adequate insurance to cover any injury or damage I may suffer or cause while participating in this activity, or else I agree to bear the costs of such injury or damage myself.  I further represent that I have no medical or physical condition which could interfere with my safety in this activity, or else I am willing to assume –  and bear the costs of – all risks that may be created, directly or indirectly, by any such condition. 
  • In the event that I file a lawsuit, I agree to do so solely in the state where Releasees’ facility is located, and I further agree that the substantive law of that state shall apply. 
  • I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. 

I agree that if I am hurt or my property is damaged during my participation in this activity, then I may be found by a court of law to have waived my right to maintain a lawsuit against the parties being released on the basis of any claim for negligence. 

* Moksha Yoga Minneapolis means Moksha Yoga Minneapolis, LLC., its officers, directors, shareholders, employees, contractors and instructors.

I, , agree to the above.

           

*If between the ages of 14-18 years, a legal guardian must consent to the conditions and terms and sign this additional release and waiver on behalf of the participant.


     
All information will be kept strictly confidential.