Ayurveda Health and Waiver Form - Adirondack Ayurveda

Name

First Last

Phone*

Cell Phone

Email*

Profile/Health History

Have you participated in a yoga class?*

Yes
No

Have you participated in a Ayurveda Workshop or Retreat?*

Yes
No

Do you Exercise on a regular basis?*

Yes
No

Do you have a history of heart problems?*

Yes
No

Have you ever had a stroke, seizure or heart attack?*

Yes
No

Have you ever experienced shortness of breath, irregular heartbeat, or pain in your chest as a result of physical activity?*

Yes
No

Do you ever have fainting or dizzy spells?*

Yes
No

Do you have High Blood Pressure?*

Yes
No

Do you have any chronic illness or pain?*

Yes
No

If yes explain

Have you been advised by your physician not to exercise?*

Yes
No

Recent Surgery or Injury

Waiver/Release

To the best of my knowledge the information supplied here is accurate. My participation in an Ayurveda or Yoga class is voluntary and at my own risk. I release Linda Tipke and Adirondack Ayurveda of any responsibility for any consequence arising from any activity I participate in this Ayurveda or Yoga class. I hereby release respective owners, instructors and assigns from any liability for any claims, demands, injuries, actions or causes of actions to my person or property arising out of or connected with the use of any of the services, equipment or facilities supplied during the Ayurveda/Yoga class. I further understand the activities may involve physical strenuous exercise and risk of bodily injury and I accept full responsibility for any activity I engage in with this Ayurveda/Yoga class. I, my heirs or legal representatives, forever release, waive, discharge and covenant negligence or other acts. I have read the above release and waiver of liability and fully understand its contents and voluntarily agree to the terms and conditions stated above.

Signature*

Date*

Printed Name*