INFORMED CONSENT AND WAIVER OF LIABILITY
FOR HEALING HART WELLNESS, LCC &
POLLIWOG KIDS YOGA AND MINDFULNESS

Please sign waiver below prior to participation in any private, group or workplace yoga sessions with Healing Hart Wellness or Polliwog Kids Yoga & Mindfulness. Waiver also required for all guests at a yoga birthday party, and for teachers in attendance at workshops/trainings.

*A waiver must be completed for EACH minor child that is in attendance of any class, workshop or event.

Name *
Name
Name of Minor Child (if applicable)
Name of Minor Child (if applicable)
Phone *
Phone
Name of Emergency Contact *
Name of Emergency Contact
Phone Number for Emergency Contact *
Phone Number for Emergency Contact
Informed Consent & Waiver of Liability *
Informed Consent & Waiver of Liability
I acknowledge that I understand that yoga is a physical activity and I am a voluntary participant. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I assume full responsibility for any and all risks, injuries or damages, which may incur through my participation or participation of my minor child(-ren), if applicable, in yoga or any other related instruction with BJ Hart, Courtney Hart or any other instructors of Healing Hart Wellness, LLC/Polliwog Kids Yoga. I affirm that I understand that it is my responsibility to consult with a physician prior to and regarding my participation, or the participation of my minor child(-ren), in any yoga session. 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 agree to make the instructor aware of any medical conditions or physical limitations of myself, or my minor child(-ren) before any instruction occurs. I agree to follow all instructions and pay attention to my own body, discontinuing activity if I begin to experience discomfort or pain. I will also make sure that my minor child(-ren) understand(s) this information. 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 participation of myself, and my minor child(-ren) if applicable, is at my own risk. I knowingly, voluntarily and expressly waive any claim that I may have against BJ Hart, Courtney Hart, and any other instructors of Healing Hart Wellness, LLC/Polliwog Kids Yoga and any facility at which I, or my minor child(-ren) if applicable, attend a yoga session including its owners for any injury, death or damages that I may sustain as a result of participating in a yoga class, training, workshop, birthday party, or pre-registered yoga session, including loss that may be caused by the negligence of the released party. I release and discharge BJ Hart, Courtney Hart and Healing Hart Wellness, LLC/Polliwog Kids Yoga from any and all liability, claim, demand or action that I may have related to loss, theft or damage of any of my, or my minor child(-ren)'s if applicable, personal property while at a facility. 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. If signing for a minor child(-ren), I affirm that I am the parent or legal guardian for any minor child(-ren) listed above in this waiver. I understand that the entirety of this waiver also applies to my minor child(-ren) even where notation may have been left out in error.