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Yoga & Qigong Class Waiver

Please fill out the following form prior to attending classes. All information on this form is kept confidential.

Individuals using a Veteran's Discount are required to provide a valid (DD214)/Veteran ID prior to attendance. Please bring this with you for in-person classes or email a copy to Jwyogi1@gmail.com.

First and Last Name

Phone

Email Address

Emergency Contact Name & Phone Number

Have you practiced yoga or qigong before

No for both

Yoga

Qigong

Yes for both

Check all that apply. Do you have numbness or pain in the following areas:

neck

shoulders

elbows

hands

wrists

hips

lower back

upper back

knees

feet

Limitations or Injuries

If at any time during the online or in perons class, you feel discomfort or strain, gently come out of the posture. You may rest at any time during the class. It is important in yoga and Qigong that you listen to your body, and respect its limits on any given day. I, the undersigned, understand that yoga and Qigong are not a substitute for medical attention, examination, diagnosis, or treatment. I should consult a physician prior to beginning any activity program, including yoga and Qigong. I recognize that it is my responsibility to notify my teacher of any serious illness or injury before every yoga and Qigong class. I will not perform any postures to the extent of strain or pain. I accept that neither the instructor, nor the hosting facility, is liable for any injury, or damages, to person or property, resulting from the taking of the class. Those under 18 years of age must have this form signed by a parent or guardian.

Initials

Today's Date

Thanks for completing the waiver!

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135 Day Street | Newington | Connecticut

Jwyogi1@gmail.com

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