TMC Intake Form
Please complete this form if you are interested in scheduling a session or class at The Metta Center
Email address *
Name and Address: *
Phone Number *
Date of Birth *
What are you interested in scheduling? *
Required
Have you had a fever in the last 24 hours? *
What is your normal body temperature? *
Do you know your O2 Saturation level? (Pulse Ox) *
Do you now, or have you recently had any respiratory or flu like symptoms, sore throat or shortness of breath? *
Have you been in contact with anyone who has been diagnosed with COVID19 within the past 14 days or who has Corona virus like symptoms? *
Where have you traveled in the past 2 weeks? *
I agree to: *
Required
Release of all claims: This release is intended to discharge in advance The Metta Center, Lise Flora Waugh, Abby Staten, and Sam Dart from and against any and all liability arising out of or connected in any way with my participation in classes or private sessions of any kind at The Metta Center, even though that liability may arise out of the negligence or carelessness on the part of these facilities or its servants, agents or employees. I further understand that accidents occasionally occur during the performance of Yoga or Yoga Therapy. Knowing these risks, I assume those risks and agree to release and hold harmless this facility (The Metta Center) and all the practitioners therein. I further understand and agree that this waiver, release and assumption of risk shall be binding upon my heirs, executor(s) and successors. Additionally, I fully understand that Covid19 is a contagious pathogen and agree to hold harmless this studio and it's practitioners and other clients in the event I should be diagnosed with Covid19. Please acknowledge by selecting AGREE below: *
Required
Thank you for taking your time to fill this form in. This information will only be used for your benefit and will not be shared. Please leave any additional comments here.
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