Intersecting Body/Mind/Spirit with Health/Contentment
Come OM to YogaCrossroads
© YogaCrossroads, Inc 2015-2016
YogaCrossroads, Inc. (1) Professional Disclosure Form and Release We   are   delighted   that   you   have   chosen   to   become   a   student   at   YogaCrossroads.      Review   and   completion   of   the information   below   will   assist   you   in   getting   the   most   out   of   your   classes   and   clarify   the   role   of   the   student   and   the teaching   staff   at   YogaCrossroads.      All   teachers   at   YogaCrossroads   have   completed   a   thorough   professional   training in yoga instruction, maintain current registry with YogaAlliance*, and abide by the YogaCrossroads Code of Conduct . Student Name:  ______________________________________________________________________ Parent/Guardian Name (when registering a child under the age of 18): _________________________________ Address:  ___________________________________________________________________________ Phone Number:  _________________ Email address**:  ______________________________________ **   Used   to   notify   students   of   emergency   class   cancellations,   workshops,   special   offers.      Email   is   used   to   send   out   regular   newsletters; newsletters can be opted out of at any time; email addresses are never shared. Month of Your Birthday:  _________   How/where did you hear about us? ___________________________ What   physical   limitations,   injuries,   surgeries   or   problems   do   you   have   that   may   impact   your   ability   to   move   and practice yoga?  Please list/explain all conditions below:   _ _ _ _______________________________________________________________________________________ _ _______________________________________________________________________________________ I   _________________________________   (print   your   name)   understand   that   yoga   includes   physical   movements as    well    as    provides    an    opportunity    for    relaxation,    stress    reduction    and    relief    of    muscular    tension.    I    further understand   that   it   is   my   responsibility   to   consult   with   my   primary   care   provider/physician   regarding   my   participation in   yoga   classes,   workshops   or   retreats.      As   is   the   case   with   any   physical   activity,   the   risk   of   injury,   even   serious   or disabling,   is   always   present   and   cannot   be   entirely   eliminated.   I   also   certify   that   I   am   in   good   health   and   am   able   to safely   participate   in   a   yoga   class.      If   I   experience   any   pain   or   discomfort,   I   will   listen   to   my   body,   adjust   the posture, continue to breathe smoothly, and ask for support from the teacher.   Occasionally,   YogaCrossroads   will   take   photographs   or   videotape   classes,   workshops   or   retreat   segments.   I   hereby grant   YogaCrossroads   the   right   to   include   me   in   such   photographs,   video-tapings   and   to   use   and   publish   the   same   in print   and/or   electronically   with   or   without   use   of   my   name,   for   any   lawful   purpose,   including   for   example   such purposes as publicity, illustration, advertising and web content. Yoga   is   not   a   substitute   for   medical   attention,   examination,   diagnosis   or   treatment.   Yoga   is   not   recommended   and   is not   safe   to   practice   under   certain   medical   conditions.   I   affirm   that   I   alone   am   responsible   to   decide   whether   to practice   yoga.   I   assume   full   responsibility   for   and   risk   of   personal   injury,   death   or   property   damage   resulting   from my   participation   in   yoga.      I   hereby   agree   to   irrevocably   release   and   waive   any   claims   that   I   have   now   or   hereafter may have against Deborah Gullo, any of the teaching staff at YogaCrossroads, or YogaCrossroads, Inc . I acknowledge that I have read and understand this document thoroughly prior to my signing below.   _____________________________ Signature of student or parent/guardian   __________Today’s Date ( 1) Also known as YogaCrossroads *In   order   to   maintain   registry   with   YogaAllliance,   a   teacher   must   complete   a   minimum   of   25   hours   per   year   of   continuing   education   related   to   the teaching   and   practice   of   yoga.      YogaAlliance   maintains   strict   standards   of   practice,   instruction   and   recommended   code   of   conduct   for   yoga   teachers   and schools.