Release Form

If you would like to access a PDF version of this release form to fill out and print or submit electronically that way, please access here.

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Birthday

MM

DD

YYYY

Emergency Contact

First Name

Last Name

Would you like to subscribe to our mailing list?

Yes, I would like to subscribe for deals and news and announcements from Monique.

No, not at this time.

I understand that yoga and gong sound therapy includes physical movements. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will adjust the posture, ask for support from the teacher/practictioner, or discontinue the practice. Yoga and sound therapy is not a substitutue for medical attention, examination, diagnosis or treatment. Specific poses are not recommended and are not safe under certain medical conditions (e.g. cardiac illness, post-surgery, etc.). The student/client assumes the risk of their practice and releases the teachers/practitioner and studio from any liability claims. I affirm that I alone am responsible to decide whether to practice yoga or experience gong sound therapy. I hereby agree to release and waive any claims that I have now or hereafter may have against Monique Derfuss.

Signature

Date

MM

DD

YYYY