Lemon Tree Yoga Intake Form and Waiver

Lemon Tree Yoga Intake Form and Waiver

Please have this filled out before your first visit. Thank you!

Name *

Birth Date *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Emergency Contact *

First

Last

Phone *

List any complications or limitations.

List any current medications and reason for taking them.

List any allergies.

LIABILITY RELEASE - By checking this box, I agree with the following terms: *

In consideration of the services of The Lemon Tree Yoga and Healing Arts Studio, including, but not limited to its agents, owners, officers, volunteers, participants, employees, affiliates, and all other persons or entities acting in any capacity on its behalf (hereinafter collectively referred to as "The Lemon Tree Yoga and Healing Arts Studio"), I HEREBY ACKNOWLEDGE AND AGREE TO IRREVOCABLY RELEASE AND WAIVE, INDEMNIFY, AND DISCHARGE THE LEMON TREE YOGA AND HEALING ARTS STUDIO OF ANY AND ALL PAST, PRESENT, OR FUTURE CLAIMS ON BEHALF OF MYSELF, MY CHILDREN, MY PARENTS, MY HEIRS, ASSIGNS, PERSONAL REPRESENTATIVES/AGENTS, AND ESTATE AS FOLLOWS: 1. I ACKNOWLEDGE that I understand that yoga includes physical movements, as well as an opportunity for relaxation, stress re-education, and relief of muscular tension. As is the case with any physical activity, THE RISK OF INJURY TO ME OR TO THIRD PARTIES, EVEN SERIOUS OR DISABLING, IS ALWAYS PRESENT AND CANNOT BE ENTIRELY ELIMINATED. If I experience any pain or discomfort, I will listen to my body, adjust the posture, and, if necessary, ask for support from the teacher or staff. I will continue to breathe smoothly. I ALSO ACKNOWLEDGE that I may be exposed to higher temperatures (ranging from 80 to 100 degrees Fahrenheit) and should that be the case, I ASSUME ALL RISKS (which may include, among other things, dehydration, heat exhaustion, heat stroke, heat cramps, and muscle strain or damage) AND UNDERSTAND IT IS MY RESPONSIBILITY TO KEEP MYSELF HYDRATED AND COMFORTABLE. 2. I further acknowledge and agree that yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I affirm that I alone am responsible to decide whether to practice yoga. I HEREBY AGREE TO IRREVOCABLY RELEASE AND WAIVE ANY AND ALL CLAIMS THAT I HAVE NOW OR HEREAFTER MAY HAVE AGAINST THE LEMON TREE YOGA AND HEALING ARTS STUDIO. 3. I expressly acknowledge, agree, and promise to accept and assume all of the risks existing in this activity. My participation in yoga is purely voluntary, and I elect to participate in spite of the risks, known or unknown. 4. I HEREBY VOLUNTARILY RELEASE, FOREVER DISCHARGE, AND AGREE TO INDEMNIFY AND HOLD HARMLESS THE LEMON TREE YOGA AND HEALING ARTS STUDIO FROM ANY AND ALL CLAIMS, DEMANDS, OR CAUSES OF ACTION, which are in any way connected with my participation in yoga or my use of The Lemon Tree Yoga and Healing Arts Studio’s equipment or facilities, online yoga classes, offsite yoga classes at selected venues including any such claims which allege negligent acts or omissions of The Lemon Tree Yoga and Healing Arts Studio and including any claims related to COVID-19 or any other illness or disease. 5. Should The Lemon Tree Yoga and Healing Arts Studio or anyone acting on its behalf be required to incur attorney's fees and other costs to enforce this agreement, I AGREE TO INDEMNIFY AND HOLD THE LEMON TREE YOGA AND HEALING ARTS STUDIO HARMLESS FOR ALL SUCH FEES AND COSTS. 6. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I FURTHER CERTIFY THAT I HAVE NO MEDICAL OR PHYSICAL CONDITIONS WHICH COULD INTERFERE WITH MY SAFETY IN YOGA, 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. 7. I FURTHER ACKNOWLEDGE AND AGREE that The Lemon Tree Yoga and Healing Arts Studio may, in its sole discretion, bar my participation in yoga or require my removal from its facilities in order to prevent injury or inconvenience to myself and others. 8. Photo Release: At times portions of our classes and events may be filmed, photographed, and/or recorded. At times our classes can take place in our physical studio location and at other times in a selected offsite venue. By signing here, you consent to the possible reproduction of your likeness and/or voice, as well as the likeness/voice of any person representing our products and/or services, and you waive any claims in connection therewith. 9. Online yoga: The Lemon Tree Yoga and Healing Arts Studio assumes no responsibility for injuries suffered while practicing these techniques at your home or any other location of your choice. Please seek a qualified medical professional before attending online yoga classes and courses. 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. By signing this NEW STUDENT RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, I acknowledge that if anyone is injured or property is damaged during my participation in yoga, I may be found by a court of law to have waived my right to maintain a lawsuit against The Lemon Tree Yoga and Healing Arts Studio on the basis of any claim from which I have released them herein. I have had sufficient opportunity to read this entire document. I FURTHER ACKNOWLEDGE I HAVE READ AND UNDERSTOOD THIS NEW STUDENT RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, AND I AGREE TO BE BOUND BY ITS TERMS.

COVID-19 PROCEDURES AND CONSENT - By checking this box, I agree with the following terms: *

I understand that to participate in classes at The Lemon Tree Yoga and Healing Arts Studio that I may be subject to the following to be allowed into the facility and to practice in the studio space, receive services, or purchase inventory items: • A staff member taking my temperature • Social distancing upon entering the studio, using designated markers to ensure I am 6 feet away from others • Wearing a facial covering to protect others upon arrival, when off your yoga mat, and when closer than 6 feet from others as advised by state order • Proper hand washing hygiene and use of hand sanitizer as needed • Covering of coughing and or sneezing • Not being of ill health or currently sick • Being asked to leave if I have a fever • Adhering to state mandate if deemed high risk by state, federal and CDC guidelines. ASSUMPTION OF RISK: By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury, illness, damage, loss, claim, liability, or expense, of any kind, that I may incur. WAIVER OF LIABILITY: I hereby release, covenant not to sue, discharge, and hold harmless The Lemon Tree Yoga and Healing Arts Studio, its employees, agents, and representatives, from all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating to COVID-19.

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