Raat Rani Collective

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

We are a community of women incorporating movement and connection to positively impact mental wellness.

New members must fill out this Raat Rani form before attending any Raat Rani events.

You must be an active member, attend at least one movement class a month, to attend social events.

Name *

Date of Birth *

YYYY

Phone number *

Emergency Contact and Phone Number *

How did you hear about us? Who referred you? *

Waiver and Liability Release Form for the Raat Rani Collective

While Harita Raja is licensed as a Medical Doctor in Maryland, Virginia and District of Columbia, she is choosing to solely engage as a leader/fitness instructor in this program. This programming is a part of Bethesda Women’s Mental Health, LLC.

Not Medical or Psychological Service: I am not engaging this leader/instructor for any medical, psychological or other healthcare services. I understand that this leader/instructor in her services pursuant to this Disclosure and Consent, does not diagnose, treat, or claim to cure any medical or psychological or other condition, and that this leader/instructor's services are not designed to replace conventional treatment methods of medical or psychological conditions. I am responsible for my own health care decision-making by obtaining any necessary consultations with appropriately licensed health care professionals such as physicians and psychologists. I agree to seek medical assistance, psychotherapy or any other appropriate physical or mental diagnosis and treatment from a duly licensed practitioner (such as a licensed medical doctor or licensed psychologist) should I find I need medical/psychological care.

No Claims or Guarantees: I understand that this leader/instructor makes no representations, claims or guarantees that my medical problems or conditions will be cured, solved, or helped by this program.

I acknowledge and agree that I understand the following, with respect to programming rendered by Harita Raja (“leader/instructor") under Bethesda Women's Mental Health, LLC

Required

Waiver and Liability Release Form for the Raat Rani Collective ("RRC")

Please read this form carefully and be aware that in signing up and participating in this identified program (“RRC”), you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you might sustain as a result of participating in any and all activities connected with and associated with said program (“RRC”). I recognize and acknowledge the risk of physical injury, sickness and accidents to participants in these programs (“RRC”), and I voluntarily agree to assume the full risk of any and all injuries, damages or loss, regardless of severity that I may sustain as a result of said participation. The accident waiver and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

I certify that I am physically fit and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this program. I certify that I am in good health and that I do not pose a health risk to the public (including but not limited to COVID).

I do hereby fully release and forever discharge this leader/instructor, other instructors and Bethesda Women’s Mental Health, LLC from any and all claims for injuries, damages, or loss that I may have or which may accrue to me and arising out of, connected with, or in any way associated with these programs/activities. I have read and fully understand the above important information, warning of risk, assumption of risk and waiver and release of all claims.

I have read and agree to all of the above terms and conditions included in this waiver.

Required

I hereby grant the Raat Rani Collective permission to use my likeness in a photograph, video, or other digital media in any and all of its communications/publications, including web-based publications and social media, without payment or other consideration.

I understand and agree to the above.

Required

By signing below, I understand and agree to the above terms. I agree that my text signature is equivalent to an electronic signature and has the same legal validity as a handwritten signature.

Please sign with the following format:

/Harita Raja/ September 1, 2023

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms