Name:  _____________________________                         Birthday:  ____/____ 

Phone: ______________________________                       Email: ______________________

Waiver, Release, and Assumption of Risk

This form is an important legal document.  It explains the risks you are assuming by beginning an exercise program.   It is critical that you read and understand it completely.  After you have done so, please print your name legibly in the spaces provided throughout the document and sign in the space provided at the bottom.

Waiver, Informed Consent, and Covenant Not to Sue

I, _________________________, have volunteered to participate in a program of physical exercise including yoga practice under the direction of Yoga-ology^tm_, Robin Hackney, and/or Shanna Haun, which will include, but may not be limited to, weight and/or resistance training, stretching, cardiovascular training, yoga and/or pilates exercises.  In consideration of Yoga-ology^tm , Robin Hackney, and/or Shanna Haun and/or Yoga-ology’s employees and contractor’s agreement to instruct, assist, and train me, I do here and forever release and discharge and hereby hold harmless Yoga-ology^tm, Robin Hackney and/or Shanna Haun and Yoga-ology’s respective agents, heirs, assigns, instructors, contractors, and employees from any and all claims, demands, damages, rights of action, or causes of action, present or future, arising out of or in connection with my participation in this or any exercise program including any injuries resulting therefrom.  THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF (1) EQUIPMENT THAT MAY MALFUNCTION OR BREAK; (2) ANY SLIP, FALL, DROPPING OF EQUIPMENT; AND (3) OUR NEGLIGENT INSTRUCTION OR SUPERVISION.

Assumption of Risk

I, ________________________, recognize that any form of exercise practiced might be difficult and strenuous and that there could be dangers inherent in exercise for some individuals.  I acknowledge that the possibility of certain unusual physical changes during exercise does exist.  These changes include abnormal blood pressure; fainting; disorders in heartbeat; heart attack; and, in rare instances, death.

I understand that as a result of my participation in an exercise program, I could suffer an injury or physical disorder that could result in my becoming partially or totally disabled and incapable of performing any gainful employment or having a normal social life.

I recognize that an examination by a physician should be obtained by all participants prior to involvement in any exercise program.  If I, ______________________, have chosen not to obtain a physician’s permission prior to beginning this exercise program with Yoga-ology^tm, Robin Hackney and/or Shanna Haun and/or Yoga-ology’s employees, instructors or contractors, I hereby agree that I am doing so at my own risk.

In any event, I acknowledge and agree that I assume the risks associated with any and all activities and/or exercises in which I participate.

I acknowledge and agree that no warranties or representations have been made to me regarding the results I will achieve from this program.  I understand that results are individual and may vary.

I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY.  BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST YOGA-OLOGY^tm, ROBIN HACKNEY, AND/OR SHANNA HAUN FOR YOUR NEGLIGENCE OR THAT OF YOUR EMPLOYEES, AGENTS, OR CONTRACTORS.

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Participant’s signature                                                        Date

Please list any limitations, health concerns or issues you would like to bring to the instructors' attention. By indicating such limitations, concerns or issues below, Yoga-ology^tm, Robin Hackney, and/or Shanna Haun are not assuming responsibility for the items listed: