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Thank you for joining our growing yoga & mindfulness community.  Our organization is devoted to increasing accessibility of yoga & mindfulness by offering our classes with a donate-what-you-can model.  Yoga & mindfulness are our vehicle to nurture healing at the individual and community level.  We are body positive, LGBTQIA+ affirming, inclusive of all religious beliefs, and welcome ALL people.  We are happy YOU are here!
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The You Belong cOMMunity Yoga Series is sponsored by our community partner You Belong Here. In this series we will utilize Yoga and Mindfulness to deepen our feelings of interconnectedness and belonging. We will go beyond western expectations and honor the ancient practice. We will view yoga as researchers describe it as “ a comprehensive system for physical and psychological health and well-being.”
Date *
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Yoga Experience *
Your Name: First & Last *
Pronouns (he/she/they etc.)
Birth Date *
Phone Number: *
Any injuries or health problems we should know?
What neighborhood do live in? *
How knowledgeable are you about the mind-body tools of grounding, centering, and orienting? *
No knowledge
Knowledgeable
How likely are you to use grounding, centering, orienting to help yourself respond to stress? *
No Knowledge
Knowledgable
In general, how do you rate your physical health? *
Poor
Excellent
In general, how do you rate your mental health? *
Poor
Excelent
In general, how do you rate your social and emotional wellbeing? *
Poor
Excelent
LIABILITY WAIVER - I understand that yoga includes physical movements as well as an opportunity for relaxation, stress reduction and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor. I will continue to breathe smoothly. I assume full responsibility for any and all damages, which may incur through participation. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. By signing, I affirm that a licensed physician has verified my good health and physical condition to participate in such a fitness program. In addition, I will make the instructor aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician's approval to participate. I also affirm that I alone am responsible to decide whether to practice yoga and participation is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against cOMmunity Yoga & Mindfulness and it's instructors. By my signature below, I certify that I am physically able to practice yoga and do hereby agree that cOMmunity Yoga & Mindfulness is not responsible or liable to me for any injury, accident or loss of personal property. I do hereby release cOMmunity Yoga & Mindfulness and its’ employees and students from any claim or cause of action which may have occurred as a result of any medical problem known or unknown which I have knowledge presently or in the future. I verify no promises or guarantees, other than those written in this agreement were made to me by cOMmunity Yoga & Mindfulness and/or any instructors employees, contractors, and/or students. I agree to follow the instructional guidelines presented by cOMmunity Yoga & Mindfulness. I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. I recognize that by voluntarily checking "I agree" this serves as complete and unconditional release of all liability to the greatest extent allowed by law in the State of California. *
Required
COVID-19 Liability Waiver - I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that cOMmunity Yoga & Mindfulness or any associated entity has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.I further acknowledge that cOMmunity Yoga & Mindfulness or any associated entity can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, cOMmunity Yoga & Mindfulness  staff, and other gym patrons and their families.‍ I voluntarily seek services provided by cOMmunity Yoga & Mindfulness or any associated entity and acknowledge that I am increasing my risk of exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment. I attest that: I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. I have not traveled internationally within the last 14 days. I have not traveled to a highly impacted area within the United States of America in the last 14 days. I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities. I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.In the last 10 days, I have not been diagnosed with COVID-19 or had a test confirming I have the virus. In the past 14 days, I have not had “Close Contact” with someone who was diagnosed with COVID-19 or had a test confirming they have the virus while they were contagious. In the past 24 hours, including today, I have not had one or more of the symptoms listed that are new or not explained by another condition. I hereby release and agree to hold cOMmunity Yoga & Mindfulness  and any related entity harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act from cOMmunity Yoga & Mindfulness  or associated entity, or that may otherwise arise in any way in connection with any services received from cOMmunity Yoga & Mindfulness  or any associated entity. I understand that this release discharges cOMmunity Yoga & Mindfulness  or any associated entity from any liability or claim that I, my heirs, or any personal representatives may have against cOMmunity Yoga & Mindfulness  with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from cOMmunity Yoga & Mindfulness  or any associated entity. This liability waiver and release extends to the gym together with all owners, partners, and employees. *
Required
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