Waiver of Liability and Media Release Statement
NOTE: This form must be completed by all attendees who signed up for "Get In Touch With Your Inner Spirit" - Yoga Class with Ustat Paintal on May 31st at 7PM. If the form is not completed prior to the event, you will not be allowed into the Zoom session.

All information provided on this form will be kept confidential between the participant and Lumos Yoga and Movement Inc.

For individuals under 18, a parent or legal guardian is required to fill out this form. Please put your child's name below and list yourself as the emergency contact.
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Email *
First and Last Name *
Phone Number *
Emergency Contact Full Name *
Emergency Contact Phone Number *
I agree that by participating in yoga classes and movement based activities, I am doing so entirely at my own risk. I agree that I am voluntarily participating in these activities and use of any facilities and premises and assume all risks of injury, illness, or death to me or my family. *
I agree to release and discharge Lumos Yoga and Movement Inc. and its instructors from any and all claims or causes of action. I agree to voluntarily give up or waive any right that I may otherwise have to bring a legal action against the company or instructors for personal injury, property damage, instructor’s negligent instruction or supervision.
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I declare myself physically and mentally sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation in a yoga and movement based class. *
I will not hold Lumos Yoga and Movement Inc. or its instructors liable for any accident or injury occurring or arising from the normal course of the program or due to a pre-existing condition not disclosed by the participant. I agree to disclose any physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in yoga and movement based classes.
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Please list any physical limitations, medical conditions or disabilities you may have below. This information allows us to offer appropriate modifications during our programs.
I authorize emergency first aid care given to me by a Yoga Instructor trained in First Aid/CPR from Lumos Yoga and Movement Inc. in the event that I become injured or ill during the program. I authorize the instructors of Lumos Yoga and Movement Inc. to call 911 on my behalf if I require immediate medical assistance.
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Occasional photos and videos may be taken during the program. I give Lumos Yoga and Movement Inc. my consent to release any photos, videos or media footage of myself on social media accounts, websites and advertisements created for marketing purposes.
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I acknowledge that I have read the Refund & Cancellation Policy at https://www.lumosyoga.com/refund-and-cancellation-policy and will not hold Lumos Yoga and Movement Inc. responsible for unreasonable cancellations or refunds for any programs.
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I represent and warrant I am signing this agreement freely and willfully and not under fraud or duress. I understand for the purpose of my yoga sessions, Lumos Yoga and Movement Inc. and I have assumed a business relationship, and I understand any social relationship does not render this waiver invalid. These exculpatory clauses are intended to apply to any and all activities occurring during the time for which I have enrolled in classes and programs with Lumos Yoga and Movement Inc. *
I provide my electronic signature as an agreement to all the terms stated above.
Please type your full name below. Parents/guardians sign for children under 18.
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