Kid & Teen Yoga Class Permission Slip & Liability Waiver
A parent or legal guardian must fill out this form for each child under the age of 18 attending a Kid Yoga or Teen Yoga class sponsored by the Kenosha Public Library. If you are 18 or 19 years old and attending a Teen Yoga class, you may sign this form yourself. This form must only be filled out once, unless there are significant changes to a child/teen's medical history or an emergency contact person.
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Child/Teen's First Name: *
Child/Teen's Last Name: *
Child/Teen's Age: *
Emergency Contact Name: *
Emergency Contact Phone Number: *
Emergency Contact's Relationship to Child/Teen: *
If the child/teen is currently experiencing any medical conditions (e.g. injury, asthma, epilepsy) that the instructor should be informed of, please specify here:
If the child/teen is currently taking medications or has serious allergies that should be made known to medical personnel in case of an emergency, please indicate them here:
I, the parent/legal guardian, agree to tell my child/teen in advance of class that yoga poses should not hurt. If a pose is too hard or if it hurts, they can and should stop! They may rest at any time during class. It is important in yoga that they listen to their body and respect its limits. *
I, the parent/legal guardian, understand that Yoga is not a substitute for medical attention, examination, diagnosis or treatment. In the event that my child/teen has an injury, sickness or anything else that may be affected by physical activity, I agree that I have consulted with a physician to ensure my child/teen can take yoga classes. I recognize that is my responsibility to notify the instructor of any illness or injury before every yoga class. *
During the global pandemic, I, the parent/legal guardian (or my assigned proxy), will stay on library premises with children ages 3-8 during the yoga program unless told otherwise by staff. *
During the global pandemic, I, the parent/legal guardian (or my assigned proxy), will do my best to help my child/teen stay at least 6 feet apart from others at all times during yoga class. *
In further consideration of permitting my child/teen to participate in the yoga class, I, the parent/legal guardian, knowingly, voluntarily and expressly waive any claim I may have against Heather Thompson, Shawn Wolf, Megan Nigh, Karen Rozzoni, Kidding Around Yoga, and the Kenosha Public Library for injury, illness, or damages that my child may sustain while on the Premises as a result of participating in the yoga class. *
I (the parent/legal guardian), my heirs, or legal representatives, irrevocably agree not to sue and forever release, waive, and discharge claims of any kind whatsoever against Heather Thompson, Shawn Wolf, Megan Nigh, Karen Rozzoni, Kidding Around Yoga, and the Kenosha Public Library for any personal injury, illness, property loss or damage, or wrongful death, whether caused by negligence or otherwise, that may arise as a result of participating in a yoga class. *
I, the parent/legal guardian, accept that neither Heather Thompson, Shawn Wolf, Megan Nigh, Karen Rozzoni, Kidding Around Yoga, the Kenosha Public Library, nor any facility hosting the class, is liable for any injury, illness, or any damages, to person or property, resulting from the taking of a yoga class. *
I, the parent/legal guardian, have read the above release and waiver of liability and fully understand its contents. *
I, the parent/legal guardian, voluntarily agree to the terms and conditions stated above and give my child permission to participate in these yoga classes. *
I hereby grant the Kenosha Public Library permission to use my child’s likeness in a photograph or video for any and all of its publications, including social media, without payment or any other consideration. *
By filling out the information below, I agree for my typed name to stand in as my signature. *
Parent or Legal Guardian's Full Name: *
Date Signed: *
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