YOGA LIABILITY WAIVER & INTAKE FOR CHILDREN AND TEENS

6270 Canal Blvd., 2

Floor  New Orleans, LA 70124

504-264-1070  www.bewellnola.com

I hereby agree to the following:

My child has permission to attend a yoga class at Sprout Pediatrics with Be Well NOLA.

My child is participating in classes during which she/he will receive information and instruction about yoga and

health. I recognize that 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 child’s participation in any physical fitness program, including yoga. I

represent and warrant that my child has no medical condition that would prevent her/his participation in

physical fitness activities.

In consideration of being permitted to participate in the yoga classes, I agree to assume full responsibility for

any risks, injuries or damages, known and unknown, which my child might incur as a result of participating in

the program. In further consideration of being permitted to participate in the yoga classes, I knowingly,

voluntarily, and expressly waive any claim I may have against the instructor, the owner, or the leaseholder of

the building for injuries or damages that my child may sustain as a result of participating in classes or

workshops held at Sprout Pediatrics.

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

Parent’s or Guardian’s Name

Child’s Name

Parent’s or Guardian’s Signature and Date

Child’s Date of Birth

Child’s Grade

Parent’s or Guardian’s Phone Number

Parent’s or Guardian’s Email Address

Please list any medical concerns the yoga teacher should be aware of:

How did you hear about this class?