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LIABILITY WAIVER & INTAKE FORM

COVID-19 RELEASE OF LIABILITY & PROCEDURES

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have limited the number of group gatherings.

RELEASE OF LIABILITY

I understand that the risk that I may become exposed to or infected by COVID-19 is my sole responsibility and Home Within Movement LLC waives all liability as aforementioned best practices will be followed. I release all liability from Home Within Movement LLC from the actions, omissions, or negligence of myself and others, including, but not limited to, Home Within Movement’s employees, volunteers, and participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance and participation in Home Within Movement LLC events and/or services of any kind. I hereby release liability and hold harmless Home Within Movement LLC, its employees, agents, and representatives from all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of Home Within Movement LLC, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Home Within Movement LLC activity or admittance into the facility. I understand my responsibility in staying home when ill, informing Home Within Movement LLC of an expected or confirmed case of COVID-19 exposure, maintaining proper hygiene, and following the proper social distancing procedures when participating or attending Home Within Movement LLC and services.

LIABILITY WAIVER & INTAKE FOR CHILDREN, TEENS and ADULTS

I hereby agree to the following:

I and/or my child has permission to attend yoga and dance classes from Home Within Movement LLC. I and/or my child are participating in classes or services during which we will receive information and instruction about dance, yoga, and health. I recognize that dance and yoga requires physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. I understand that it is my responsibility to consult with a physician prior to and regarding my and/or my child’s participation in any physical fitness program, including yoga and dance. I represent and warrant that I and/or my child have no medical condition that would prevent us from participation in physical fitness activities. In consideration of being permitted to participate in the yoga and dance classes, I agree to assume full responsibility for any risks, injuries or damages, known and unknown, which I and/or my child might incur as a result of participating in the program. In further consideration of being permitted to participate in the yoga/dance classes, I knowingly, voluntarily, and expressly waive any claim I and/or my child may have against the instructor, the owner, or the leaseholder of the building for injuries or damages that I and/or my child may sustain as a result of participating in classes or workshops conducted by Home Within Movement LLC. If I and/or my child participates in other classes or events at Home Within Movement LLC, I will also assume full responsibility for any injuries that may result from our participation, with the same considerations that this waiver stipulates for yoga and dance.

PHOTO RELEASE:

I give my permission for Home Within Movement LLC to use my or my child’s image (photo or video) for website or newsletter and teaching seminars. I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

Today's Date: June 14, 2024

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Please list any medical concerns the instructor should be aware of.
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Please list any medical concerns the instructor should be aware of.
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Please list any medical concerns the instructor should be aware of.
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Please list any medical concerns the instructor should be aware of.
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Please list any medical concerns the instructor should be aware of.
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Please list any medical concerns the instructor should be aware of.
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Please list any medical concerns the instructor should be aware of.
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Please list any medical concerns the instructor should be aware of.
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Please list any medical concerns the instructor should be aware of.
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Please list any medical concerns the instructor should be aware of.
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last 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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Please list any medical concerns the instructor should be aware of.
Parent or Guardian's 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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