Emma Stern Movement and Somatics Student Waiver Agreement and Release of Liability
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Untitled Title
First Name and Last Name *
Email Address *
Parent or Guardian's First and Last Name if participant is under 18
Parent or Guardian Email Address if under 18
How did you hear about Emma's yoga, movement, and somatic work? Please provide names so Emma can send a thank you notes for referrals.
How long have you been practicing yoga?
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Is there anything you would like me to know about your body? (injuries, pregnancy, postpartum, hypermobility?)
I am, of my own volition, participating in movement, yoga, and somatic activities offered by Emma Stern, during which I will receive information and instruction about topics including but not limited to movement technique; yoga flow and postures; strength conditioning; isometric exercises; activity flexibility; acrobatics; mobility and contortion; breathwork; meditation; and somatic inquiry. *
Required
I understand that yoga and movement activities can include challenging physical activities and require physical effort. If at any time during the class, I feel discomfort or strain, I can gently come out of the posture. I understand that I may rest at any time during the class. *
Required
I recognize that with yoga and movement activities, as is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. *
Required
I understand that yoga may cause and/or aggravate a physical injury or medical condition. I understand that it is my responsibility to consult a physician and therapist prior to and regarding my participation in any activity program, including yoga, movement, and somatic work offered by and provided by Emma Stern, whether in-person or online. *
Required
I represent and warrant that I have accurate, current, and complete medical and mental health information. I further represent and warrant that I am in good health and physical condition and have no medical or mental health condition that would prevent me from participating in any aspect of yoga, movement, or somatic activities with Emma Stern, whether in-person or online. I realize that I am participating in yoga, movement, and somatic activities at my own risk. *
Required
I understand that yoga, movement, and somatic activities are not a substitute for medical or psychiatric attention, examination, diagnosis or treatment. I understand that Yoga, movement, and somatic activities are not recommended and are not safe under certain medical and mental health conditions. *
Required
I understand and affirm that I alone am responsible to decide whether to participate in yoga, movement, and somatic activities. *
Required
In consideration of being permitted to participate in Emma Stern classes, whether in-person or online, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in any class or activity. In further consideration of being permitted to participate in Emma Stern classes, whether in-person or online, I expressly, voluntarily and irrevocably release and waive any claims that I have now or may have hereafter for any reason against Emma Stern Movement and Somatics, its owners, employees, instructors, teachers, staff, independent contractors (each individually a “Released Party”) even if the Claim arises from the carelessness or negligence of myself or any Released Party. I agree to indemnify and hold harmless each Released Party from any loss or liability incurred in defending any Claim made by me or anyone making a Claim on my behalf, even if the Claim is alleged to or did result from the carelessness or negligence of any Released Party or anyone else. *
Required
I understand that I may be photographed during an Emma Stern class. I understand that these photographs may appear in promotional materials, social media posts, and other media. I understand and hereby consent to the use of my image that may appear in any such photograph or video. *
Required
I have read the above release and waiver of liability and fully understand and agree to each of the above statements. By typing my name or my child's name below I am electronically signing this waiver and voluntarily agree to the terms and conditions stated above. I understand that my signature is a complete and unconditional release of all liability to the greatest extend allowed by the State of California. This electronic signature is a legal equivalent of a manual signature on this waiver. This agreement shall be construed in accordance with, and governed by, the laws of the State of California. This signature is binding from this day forth. *
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This form was created inside of Emma Stern Movement and Somatics.