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Kingfisher Yoga

New Client Intake Form

Emergency Contact:

Medical Profile:

Do you have the following medical conditions? Select all that apply.

If you have checked any of these conditions or have any injuries you think we would find helpful in working with you, please list any details:

Client Waiver:

I hereby agree without reservation to the following:

I agree that participation in physical exercise in any form, including yoga, carries risks, dangers and hazards, including the risk of personal injury.

I understand that yoga may require some physical exertion, which may at times be strenuous.

I understand that I should seek medical advice from suitably qualified medical professionals before undertaking any new physical exercise program, including classes and workshops.

I warrant that I am in good physical condition and do not suffer from any known medical condition which would prevent me from safe participation in yoga classes or workshops offered by Kingfisher Yoga.

I confirm that I have made Kingfisher Yoga aware of any medical or health problems that I currently suffer from or are likely to suffer from.  I agree to notify Kingfisher Yoga and its teachers of any health problems that I may suffer from time to time.

I understand and accept that it is my responsibility to ensure that I select the appropriate level of classes or workshops for my skills and abilities, as well as for any health conditions I have and to ensure that I do not exceed my limits during yoga classes or workshops offered by Kingfisher Yoga.

I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in yoga classes or workshops offered by Kingfisher Yoga.

I release, waive and discharge Kingfisher Yoga, Carla Wiessing, associated teachers, staff or employees from any and all liability (whether in contract or in tort or under any statute or common law whatsoever), for any injury, illness, illness related to COVID-19, loss, or damage, expense or other mishap I sustain arising from or out of, or in any way directly or indirectly connected with my participation in yoga classes offered by Kingfisher Yoga.

I accept full responsibility for any loss, theft or damage to any personal property I bring onto the premises.

Kingfisher Yoga will be cleaning and sanitizing all mats, blocks, blankets, studio floors, restrooms and any other accessories needed for class that are property of Kingfisher Yoga after each class and on a daily basis.

I have read the terms of this document carefully and fully understand its contents and meaning.  I voluntarily agree to these terms.

If participants are under age 18 years of age, parent or legal guardian's consent is required.


Your information has successfully been submitted.

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