Child’s name:
Parent/guardian name:
Release of liability
I, as the parent or legal guardian of the child identified above, consent to his/her participation
in The Zen Corner’s yoga class.
The instructor will take all reasonable care to ensure the classes are fun and safe; however, I
understand that my child will be engaging in some physical activity and therefore may
involve some risk of injury. I assume these risks and take full responsibility for any personal injury
sustained by my child which might occur as a result of participating in this programme.
I agree to discharge Berengere Marie Moore and The Zen Corner from any claim, cause of
action or liability relating to any incident that may occur in connection to my child’s
participation in the above mentioned yoga class.
Parent/Guardian Signature: ______________________________ Date: _________________________
Media Consent
I give consent for my child to be photographed or filmed while participating in the yoga class
and for photos and videos which include images of my child to be used by Berengere Marie
Moore and The Zen Corner for promotional purposes. I understand that my child will not be
identified by name, nor will any compensation be extended for such use.
Parent/Guardian Signature: ______________________________ Date: _________________________
