Name *

First Name

Last Name

Phone *

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Birth Date *

MM

DD

YYYY

Emergency Phone Number or Contact *

(###)

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Consent release: *

I understand that yoga includes physical activity and, as with all physical activity, there is the risk of injury or varying types and degrees, which risk cannot be entirely eliminated. If I experience any pain or discomfort, I agree that I will discontinue the activity, and ask for support from the instructor. I assume full responsibility for any and all damages which may be incurred as a result of my participation in the yoga activities. 
I understand that yoga is not a substitute for medical attention, examination, diagnosis or treatment, nor is yoga recommended or safe under certain medical conditions. By signing, I affirm that a licensed physician has verified the status of my health and physical condition as sufficient to allow me to participate in the physical activity required by the yoga program. I agree that I will make the instructor aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician's approval to participate. I also affirm that I alone am responsible to decide whether to practice yoga and my participation is at my own risk. I agree to irrevocably release and waive any claims that I have now or may have hereafter against Alex Jeffers and Word Life Yoga LLC. I agree to irrevocably release and waive any claims that I have now or may have hereafter against Alexa Rae & Wissahickon Brewing Company LLC (when practicing yoga at Wissahickon Brewing Company). 

I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. I am signing this agreement voluntarily and recognize that my signature serves as complete and unconditional release of all liability to the greatest extent allowed by law in the State of Pennsylvania.
 By signing my name below, I acknowledge that I am signing this waiver to hold harmless Alex Jeffers, Alexa Rae, Wissahickon Brewing Company and Word Life Yoga LLC.

I Agree to the liability release policy