Intake & Waiver
for clients taking in-person and/or online or recorded classes with DielleCiesco.com and subsidiaries
Email address *
Full Name *
Are you currently seeing a health care provider for a health issue I should know about or have you had any surgeries, accidents, injuries, major illnesses or hospitalizations which may be relevant to the practice of yoga as a mind/body/spirit science? *
Required
Are you physically active? *
Required
1) 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 body 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 that I have decided to participate voluntarily and without the approval of my physician. 3) I certify that I am physically well and suffering from no medical or mental problems, conditions (including pregnancy), impairments, diseases, or other illness that would prevent my full participation 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. 4) I, my heirs, 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 death, injury, accident, illness, legal and medical fees sustained now or in the future resulting from my participation in any exercise/yoga activity, program or workshop. 5) I understand that Beth Ciesco (Dielle) may take photographs and/or video footage during classes for Tribe member use, Youtube, and/or promotional purposes 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. *
Please type your full name below to signify acceptance of the above.
I have read the online privacy policy (https://dielleciesco.com/privacy-policy/) and agree to the terms. *
Required
I opt-in to correspondence from DielleCiesco.com.
What is today's date? *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy