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Apotheke Yoga Student Registration and Waiver of Liability
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Email *
Name & phone number *
Date of birth *
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What is your yoga experience? *
Have you been cleared by a doctor for activity or to begin a new workout regimen? *
Do you have any injuries we should be aware of? *
Apotheke Yoga operates on a sliding-scale for our memberships. Please respond that you are aware that this studio operates on a sliding-scale with suggested minimum support levels listed on our website. If you need further assistance financially this will be evaluated by the studio owner on a case by case basis. Please note that any profit made is used for expenses that incur at Apotheke Yoga and/or donations to local organizations. Levels of support are found at www.apothekeroots.com under the 'pricing' tab. *
Waiver specific to Aerial Yoga/Hammock                                Waiver Specific to Aerial Yoga Activities: 1. I represent that I am physically capable and of participating in aerial yoga suspension fitness provided by Apotheke Roots Yoga and Wellness LLC .2. I understand the yoga and physical exercise, activity, or fitness program should not be taken without the consent of a doctor or physician and I am responsible for undertaking that consent.3. I agree that I am engaging in the activity of yoga, fitness, and aerial suspension classes at my own risk.4. I agree that I am voluntarily participating in the aerial yoga class and the use of premises and facilities provided and assume all risk of injury, illness, or death.5. I agree that Apotheke Roots Yoga and Wellness LLC is not responsible for any loss or damage to personal property.6. I understand that Aerial yoga may be extremely demanding and I take full responsibility for knowing, monitoring and acting within my abilities, and learning and incorporating any modifications, necessary to proceed in a safe manner.7. I agree that Apotheke Roots Yoga and Wellness LLC and it’s directors, instructors, assistants, and employees, shall not be liable or responsible for any injuries to me which may occur as a result of my use of all amenities and equipment provided by Apotheke Roots Yoga and Wellness LLC. Including (a) sudden and unforeseen malfunctioning of equipment (b) Instruction by a teacher or assist (c) slipping or falling while in the facility.8. I acknowledge that I have read and understand the waiver and release and understand that it is a release of all liability. 9. I expressly agree that this release shall be binding up my heirs, executors, administrators, and assigns .By signing this waiver. I am stating that I do not have any of the following conditions. • easy onset vertigo • inner ear problems • severe balance issues • severe muscle spasm • severe neck or back pain • recent surgery • osteoporosis or bone weakness • glaucoma • very high or low blood pressure • propensity for fainting • recent concussion or head injury • severe arthritis • head cold, flu or sinusitis • hiatal hernia • disc herniation • pregnancy beyond the 1st-trimester (doctor approval if after 1st trimester) • recent stroke • radiculitis • cerebral sclerosis • trauma • Botox within 24 hours Please type name below to acknowledge this agreement. *
 DISCLAIMER - PLEASE READ -The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people . Apotheke Roots Yoga and Wellness LLC has put in place preventative measures to reduce the spread of COVID-19 for their classes; however, Apotheke Roots Yoga and Wellness LLC cannot guarantee that you will not become infected with COVID-19. Further, attending our classes could increase your risk’s risk of contracting COVID-19. By attending these classes, you acknowledge the contagious nature of COVID-19 and voluntarily assume the risk you may be exposed to or infected by COVID-19 by attending classes offered by Apotheke Roots Yoga and Wellness LLC and that such exposure or infection may result in personal injury, illness, permanent disability, and death .You understand that the risk of becoming exposed to or infected by COVID-19 when attending Rock and Apotheke Roots Yoga and Wellness LLC's classes may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Apotheke Roots Yoga and Wellness LLC employees, teachers, and program participants and their families. You voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that you may experience or incur in connection with your attendance and participation at these classes. You hereby release, covenant not to sue, discharge, and hold harmless Apotheke Roots Yoga and Wellness LLC, their employees, agents, and representatives, of and from all claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. You understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Apotheke Roots Yoga and Wellness LLC, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in classes and programs. If you have any questions, please call 817-381-2290 for more information.                                                                           Apotheke Roots Yoga and Wellness LLC AGREEMENT OF RELEASE AND WAIVER OF LIABILITY Please remember that it is your responsibility to inform the instructor of your limitations (such as back, neck, shoulder or knee problems and/or pregnancy) before class begins. I represent and warrant that I am in good physical health and do not suffer from any medical condition which would limit my participation in the classes offered at Apotheke Roots Yoga and Wellness LLC. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any of the yoga classes, programs, aerial, or workshops. I understand the risks associated with the activities offered by Apotheke Roots Yoga and Wellness LLC and I agree to follow all instructions so that I may safely participate in classes, workshops, or other activities. I hereby WAIVE AND RELEASE Apotheke Roots Yoga and Wellness LLC, its owners, officers, employees, and instructors from any claim, demand, cause of action of any kind resulting from or related to my participation in the programs offered at the facility. In taking part in the yoga classes, workshops or other activities at Apotheke Roots Yoga and Wellness LLC, I understand and acknowledge that I am fully responsible for any and all risks, injuries, or damages, known or unknown, which might occur as a result of my participation in the classes, workshops, or other activities. I have read the above release and waiver of liability and fully understand its content. I am legally competent to sign and voluntarily agree to the terms and conditions stated above. Please practice mindfully and enjoy the many benefits of practicing with Apotheke Roots Yoga and Wellness LLC.                                                                    Please type name below to acknowledge this agreement.
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