COVID 19 Customer Risk Acknowledgement Form
For your safety and the safety of our community, please read and confirm the below statements.
Email *
Name *
In the past 14 days, I have experienced... *
Yes
No
Above normal Fever (99°F or higher)
Unexplained body aches or pain
Coughing
Sore throat
Shortness of breath
Chills with or without body aches
Recent loss of sense of smell or taste
Unexplained sores on soles of feet
Unusual fatigue
Non-allergy related runny nose
I understand that I need to wear a mask at all times while indoors. *
Required
Addendum: Coronavirus/COVID-19

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. Urban Yoga Spa has put in place preventive measures to reduce the spread of COVID-19. However Urban Yoga Spa cannot guarantee that you will not become infected with COVID-19.
ASSUMPTION OF RISK: By digitally signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury, illness, damage, loss, claim, liability, or expense, of any kind, that I may incur.
WAIVER OF LIABILITY: I hereby release, covenant not to sue, discharge, and hold harmless Urban Yoga Spa, its employees, agents, and representatives, from all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating to COVID-19.
Please read carefully; I hereby agree to the following:
I agree and acknowledge that I am fully aware that participation in this activity may involve risks and I accept all the risks of participating. I will progress at my own pace and I understand my physical limitations, so I am sufficiently self-aware to stop physical activity before I become ill or injured. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the yoga classes. In consideration of being permitted to participate in the yoga classes, I knowingly, voluntarily, and expressly waive any claim I may have against Urban Yoga Spa for injuries or damages that I may sustain as a result in participating in the yoga classes. My digital signature acknowledges that I shall not now, or at any time in the future, bring any legal action against Urban Yoga Spa, the instructor, and/or any other person who may teach at Urban Yoga Spa; and that this waiver is binding on me, my heirs, my spouse, my children, my legal representatives, my successors, and my assigns. If I am pregnant, or become pregnant, or am postnatal, my digital signature verifies that I am participating in yoga at Urban Yoga Spa with my doctor’s full approval. If you are under 18, you must have a parent’s digital signature. My digital signature is binding to this liability waiver from this day forth.
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