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little om BIG OM Waiver and Release

Please complete the form below prior to participating in little om BIG OM Programming!

Participation in Yoga class includes, but is not limited to, participation in meditation techniques, yogic breathing techniques, and performing various Yoga postures. Yoga postures, or asanas, are designed to exercise every part of the body - stretching and toning the muscles and joints, the spine and the entire skeletal system. They also work on the internal organs, glands and nerves. Yoga incorporates sustained stretching to strengthen muscles and increase flexibility

I understand that it is my responsibility to consult with a medical doctor prior to and regarding the above listed students participation in yoga class, and I confirm that the above listed students have no medical condition which would prevent full and safe participation in yoga class.

I assume responsibility to update little om BIG OM, its owners, instructors and Jamie Gale of any changes in the medical conditions of the above listed students that might affect their condition to fully and safely participate in yoga class. If I am pregnant, or become pregnant, or am post-natal, my signature verifies that I am participating in Yoga with my doctor's full approval.

I understand that participation in Yoga class exposes participants to possible risks, including the risks of personal injury, death, and other damages and losses. I am fully aware of these risks and hereby release, discharge, hold harmless and covenant not to sue: little om BIG OM, its owners, instructors, Jamie Gale and each of their assistants, associates, insurers, and all other persons and parties who may be liable as a result of their negligence for any and all injuries and damages that may be sustained by the undersigned or by the above named students arising from, or in any way related to participation in Yoga class.

I acknowledge and agree that this waiver is binding on me and my heirs, spouse, children, legal representatives, successors and assigns. I have read the above conditions and waiver and fully understand their contents and voluntarily agree to them.

I hereby agree to the above conditions and waiver on behalf of myself, and as parent or legal guardian on behalf of the above listed minor children/students.

I have read the attached waiver of liability agreement.  I realize I am not required to sign the agreement. 

I have considered that if this waiver of liability was not as broad as it is, the cost for my participation in Yoga class would be considerably higher, and as I do not wish to pay a considerably higher cost, I waive the right to bargain for different waiver of liability terms.

little om BIG OM occasionally takes pictures and videos of activities and participants during yoga classes.  These photos are used on the little om BIG OM website, in print information, and on social media pages. little om BIG OM will never reference participants by name or provide any specific information regarding individuals. little om BIG OM also will never sell these pictures; and will use them exclusively for little om BIG OM's purposes. While this can be a fun way for you to see what happens in class class, we understand if you would prefer not to have photos used of you or your child. If you have concerns about this or would like little om BIG OM to avoid photographing you or your children, please contact us directly at info@littleomBIGOM.com. 

I understand that photos of me or my children may be taken and I grant little om BIG OM permission to use these photos as outlined above unless I contact little om BIG OM at info@littleomBIGOM.com to deny this permission.

 

First Participants Name

First Name*

Last Name*
First Participants Date of Birth*
First Participants Information

Medical Information: Allergies, restrictions, additional information - If none, leave blank

Location of Class (i.e. Best Learning Preschool, or Harmony Yoga Studio)
First Participants Signature*
Second Participants Name

First Name*

Last Name*
Second Participants Date of Birth*
Second Participants Information

Medical Information: Allergies, restrictions, additional information - If none, leave blank

Location of Class (i.e. Best Learning Preschool, or Harmony Yoga Studio)
Third Participants Name

First Name*

Last Name*
Third Participants Date of Birth*
Third Participants Information

Medical Information: Allergies, restrictions, additional information - If none, leave blank

Location of Class (i.e. Best Learning Preschool, or Harmony Yoga Studio)
Fourth Participants Name

First Name*

Last Name*
Fourth Participants Date of Birth*
Fourth Participants Information

Medical Information: Allergies, restrictions, additional information - If none, leave blank

Location of Class (i.e. Best Learning Preschool, or Harmony Yoga Studio)
Fifth Participants Name

First Name*

Last Name*
Fifth Participants Date of Birth*
Fifth Participants Information

Medical Information: Allergies, restrictions, additional information - If none, leave blank

Location of Class (i.e. Best Learning Preschool, or Harmony Yoga Studio)
Sixth Participants Name

First Name*

Last Name*
Sixth Participants Date of Birth*
Sixth Participants Information

Medical Information: Allergies, restrictions, additional information - If none, leave blank

Location of Class (i.e. Best Learning Preschool, or Harmony Yoga Studio)
Seventh Participants Name

First Name*

Last Name*
Seventh Participants Date of Birth*
Seventh Participants Information

Medical Information: Allergies, restrictions, additional information - If none, leave blank

Location of Class (i.e. Best Learning Preschool, or Harmony Yoga Studio)
Eighth Participants Name

First Name*

Last Name*
Eighth Participants Date of Birth*
Eighth Participants Information

Medical Information: Allergies, restrictions, additional information - If none, leave blank

Location of Class (i.e. Best Learning Preschool, or Harmony Yoga Studio)
Ninth Participants Name

First Name*

Last Name*
Ninth Participants Date of Birth*
Ninth Participants Information

Medical Information: Allergies, restrictions, additional information - If none, leave blank

Location of Class (i.e. Best Learning Preschool, or Harmony Yoga Studio)
Tenth Participants Name

First Name*

Last Name*
Tenth Participants Date of Birth*
Tenth Participants Information

Medical Information: Allergies, restrictions, additional information - If none, leave blank

Location of Class (i.e. Best Learning Preschool, or Harmony Yoga Studio)
Participants Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardians Email Address

Email*
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardians Name

First Name*

Last Name*
Parent or Guardians Date of Birth*
Parent or Guardians Information

Medical Information: Allergies, restrictions, additional information - If none, leave blank

Location of Class (i.e. Best Learning Preschool, or Harmony Yoga Studio)
Parent or Guardians Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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