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Yoga Liability Waiver and Release Form

Jessi Rodriguez Yoga

112 N. Monroe St.

Streator, IL 61364

815-674-9249

Birthday
Month
Day
Year
Are you currently pregnant?
Yes
No
Not applicable

Release of Liability:

1. I recognize that activities related to yoga, workshops, retreats and/or trips involve physical activities which may be strenuous and may cause injury. I understand that I must judge my own capabilities with respect to any activity. By my participation in any activity or practice taught at or by Jessi Rodriguez Yoga (Jessica Rodriguez) in any location, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, that I may incur.

2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any activity. I represent and warrant that I am physically and mentally fit and have no medical condition which would prevent my full participation in any activity. I acknowledge that it is my responsibility to inform the instructor of any injury or other condition that might affect my ability to participate in any activities, and to inform the instructor immediately if an injury occurs.

3. Although I acknowledge there is no obligation for any person to provide medical care during, prior to or after any activity related to Jessi Rodriguez Yoga. I hereby give permission for staff to provide first aid, administer prescribed or OTC medication as prescribed or directed by the participant, and/or aid in seeking emergency medical treatment as needed. IN THE EVENT MEDICAL TREATMENT IS PROVIDED TO ME, I HEREBY WAIVE ANY CLAIM AGAINST THE COLLAB/ JESSICA RODRIGUEZ YOGA.  JESSICA RODRIGUEZ, EMPLOYEES, SUBCONTRACTORS AND/OR AGENTS FOR ANY INJURY, DAMAGES OR DEATH CAUSED BY THE NEGLIGENT PROVISION OF SUCH MEDICAL CARE.


4. I, MY HEIRS OR REPRESENTATIVES RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE OR ASSERT CLAIM AGAINST JESSICA RODRIGUEZ YOGA, JESSICA RODRIGUEZ, EMPLOYEES, SUBCONTRACTORS AND/OR AGENTS FOR ANY INJURY, DAMAGES OR DEATH CAUSED BY THEIR NEGLIGENCE. I KNOWINGLY, VOLUNTARILY AND EXPRESSLY WAIVE ANY CLAIM I MAY HAVE AGAINST BREATHE HEALING STUDIO, LLC, JESSICA RODRIGUEZ, EMPLOYEES, SUBCONTRACTORS AND/OR AGENTS FOR ANY INJURY, DAMAGES OR DEATH AS A RESULT OF PARTICIPATING IN BREATHE HEALING STUDIO, LLC’S ACTIVITIES OF ANY KIND.

5. I have carefully read this waiver and release, I understand that I have the opportunity to negotiate its terms with the owners and staff of Breathe Healing Studio. By signing this form, I voluntarily agree to the above terms, releasing Breathe Healing Studio from its own negligent acts.

I consent to the above terms and conditions. 


Notes: Jessi Rodriguez Yoga (JRY) reserves the right to refuse service at any time. JRY may use any student related video, picture or audio recording for JRY’s own purposes both public and private. JRY is not responsible for lost, stolen or damaged items.


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