Intake & Waiver
All clients and students, in order to participate in group classes, events, or private sessions (yoga, energy healing, meditation, voicework, breathwork, etc.,) on offer by Beth Ciesco (Dielle), DielleCiesco.com, and her affiliates are in agreement with the following:
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Email *
Full Name *
Your physical address for emergency purposes only: *
Your local long-dial (out of state) emergency number (911) including area code: *
In case of emergency, who shall I notify:
In the following space, please list any injuries, diagnoses, treatments, surgeries, medications, or limitations you feel I should know. Please include all that apply: Heart Disease, High Blood Pressure, Diabetes, Stroke, Cancer, Seizures, Thyroid Disease,  Glaucoma/Detached Retina, Currently Pregnant. If none, write "none". *
If you grant me permission to speak with your doctor, please give me the name and contact information of your physician. Otherwise, leave blank.
What do you hope to gain out of our session(s) together? *
1) I certify that I am in adequate health and suffering from no medical or mental problems, conditions (including pregnancy), impairments, diseases, or other illness that would prevent my full participation and/or increase my risk of injury and/or illness as a result of partaking in these programs or that could risk the health of others. It is my ongoing responsibility to notify Beth Ciesco (Dielle) of any pregnancies, surgeries, accidents, injuries, major illnesses or hospitalizations which may be relevant to the mind/body/spirit practices in which I am voluntarily participating. Further, it is my responsibility to practice without strain or discomfort. I agree to judge my own capabilities and will listen with the utmost care to my physical, emotional, mental and spiritual bodies ceasing any movement, posture, or activity that causes me concern, informing the teacher immediately.   2) I acknowledge that I have either had a physical examination and/or have been given permission from my physician to participate in a yoga-based exercise program or alternative well-being practice or that I have decided to participate voluntarily and without the approval of my physician. 3) I understand that my participation may aggravate pre-existing injuries or conditions. I also understand that I may experience muscle, back, neck or other injuries or “healing crisis” as a result of my participation. In consideration for being accepted as a client or student, I agree to assume full responsibility for any risks, injuries, or damages known or unknown, which I might incur as a result of my participation.  4) I, my spouse, heirs (including the unborn), and/or legal representatives, do hereby forever waive and release Beth Ciesco (Dielle), her members, teachers, agents and employees from any and all liability and responsibility from personal injury, mental suffering or distress, death, accident, illness, legal actions and medical fees or expenses sustained now or in the future resulting from my participation in any exercise/yoga activity, course, session or workshop, even in cases of negligence.  5) I understand that Beth Ciesco (Dielle) may take photographs and/or record video footage during classes for promotional purposes including but not limited to DielleCiesco.com, Youtube, and other social sites, and I hereby grant permission for my likeness to appear without exception or time limit.  6) I acknowledge that I am signing this agreement voluntarily, and intend by my signature for this to be a complete and unconditional release of liability to the greatest extent allowable by law and understand it to be construed in accordance with and governed by the laws of France. All actions, claims, suits and proceedings relating to this agreement shall be brought in a court of competent jurisdiction in France. In case any provision of this agreement shall be held invalid, illegal, or unenforceable, it shall not affect any other provision of this agreement which will remain intact.  Updated September 4, 2021 *
Please type your full name below to signify acceptance of the above.
Refund Policy: At least 24-hour notice of cancellation is necessary for a full refund. If under 24-hours, credit towards rescheduling will be on a case-per-case basis. Please contact me directly at dielleciesco.com to arrange. *
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I have read the online privacy policy (https://dielleciesco.com/privacy-policy/) and agree to the terms. *
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