Amore Tea / T-Yoga – Student Health Waiver

Amore Tea Health Waiver

Terms and Conditions

Please complete our Health Waiver Form before your first class, session or event.

Please notify the teacher of any injuries or illness prior to attendance.

Name*

First NameLast Name

Date of Birth*

MonthDayYear

Email Address*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mobile Number*

Area CodePhone Number

Occupation *

Would you like to learn about special offers/discounts and upcoming events via email?*

YesNo

Have you regularly practised yoga in the past?*

YesNo

Have you had, or do you have any of the following?

	Yes	No
Are you a male over 35 or female over 45 and not used to regular exercise?
Recent hospitalisation and/or surgery
Are you pregnant?
High blood pressure (>140/90) (if yes, please check with your doctor before commencing this exercise program)

Have you had, or do you have any heart condition? If yes, please detail below.

If you answered yes to any of the questions above, please check with your doctor before commencing this exercise program or session.

If you have checked and been cleared by your doctor, please provide your doctors details below.

Have you had, or do you have any of the following?

	Yes	No
Gout, Stroke, Diabetes, Epilepsy, Hernia, Glandular Fever, Rheumatic Fever
Dizziness or Fainting
Arthritis, Asthma, Cramps, Muscular pain
Any pain/injuries to the neck, back, knees, ankles

If you answered "yes" above, please explain and add any other conditions that would cause you to modify your exercise program (please specify)

How did you hear about us?*

Terms & Conditions – Health Waiver

This form must be read and submitted before attending your first Amore Tea, Wildflower Healing or Reiki Session(s) or Yoga class or event. If you are a regular attendee and your circumstances change, you will need to submit a new form before coming along to another class.
Please know that all information you provide in this form will be treated as confidential.

So that you have the best experience with Amore Tea please provide any details that may affect your ability to participate in a class , session or event. If you have any injuries or health concerns, please check with your medical practitioner before attending or email us at hello@amoretea.com.au.

I confirm and agree that the following terms, conditions and undertakings apply to the Amore Tea, Wildflower Healing or Reiki Session(s) or Yoga class or event provided to me by Amore Tea.

I have been examined by a licensed medical practitioner (“Practitioner”) within the past six months and have been found by the Practitioner able to perform all vigorous stretching and the Amore Tea, Wildflower Healing Session or Yoga class or event, which I am to perform during my enrolment with Amore Tea.

I will faithfully follow all instructions given to me by Amore Tea and its teachers or practitioners as to when, where and how to perform the instructed exercises. I understand that yoga and/or wildflower healing or Reiki sessions include physical movements as well as an opportunity for relaxation, stress reduction and relief of muscular tension. Participation in Amore Tea, Wildflower Healing or Reiki Session(s) or Yoga classes or event includes, but is not limited to, participation in meditation techniques, yogic breathing techniques, sitting or lying for extended periods and performing various yoga postures.

I agree and acknowledge that participation in any Amore Tea, Wildflower Healing or Reiki Session(s) or Yoga classes or events could constitute a risk of serious injury to me, including permanent paralysis or death. I voluntary and knowingly recognise, accept and assume this risk and warrant that I am physically fit and able to perform the exercises provided.

My signature acknowledges I understand that in Amore Tea, Wildflower Healing or Reiki Session(s) or Yoga classes or events, I will progress at my own pace. If I experience any pain or discomfort, I will listen to my body, adjust the posture and ask for support from the yoga teacher (the “Teacher”). I will continue to breathe smoothly. If at any point I feel overexertion or fatigue, I will respect my body’s limitations and I will rest before continuing Amore Tea, Wildflower Healing Sessions or Yoga classes or events.

I understand these sessions given are for the purpose of stress reduction and relaxation to promote healing. I understand very clearly they are not a substitute for medical attention, examination, diagnosis or treatment. I understand Reiki, Tea or Healing Practitioners or employees or Amore Tea do not diagnose conditions nor do they prescribe, perform medical treatment, nor interfere with the treatment of a licensed medical professional. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailments I have. I affirm that I alone am responsible to decide whether to practice with or attend a session with Amore Tea, Wildflower Healing, Reiki or Yoga classes or events.

By signing my name below, I acknowledge that participation in yoga classes exposes me to a possible risk of personal injury. I am fully aware of this risk. I hereby consent to receive medical treatment that may be deemed advisable in the event of injury, accident and/or illness during any Amore Tea, Wildflower Healing or Reiki Session or Yoga class or events.

I hereby take action for myself, my executors, administrators, heirs, next of kin, successors and assigns as follows: I (a) irrevocably WAIVE, RELEASE AND DISCHARGE FROM ANY AND ALL LIABILITY for my death, disability, personal injury, property damage, property theft or actions of any kind which hereafter may occur to me, including my traveling to and from yoga classes, Teacher and Amore Tea / T-Yoga, who is hosting these classes and where sessions are being held, and each of their directors, officers, employees, volunteers, representatives and agents; and (b) INDEMNIFY, HOLD HARMLESS AND AGREE NOT TO SUE the entities or persons mentioned in this paragraph as to any and all liabilities or claims made as a result of participation in the yoga classes, whether caused by the negligence of releases or otherwise.

My signature further acknowledges that I shall not now or at any time in the future bring any legal action against teacher and/or Amore Tea /T-Yoga / Wildflower Healing/Reiki ; and that this waiver is binding on me, my heirs, my spouse, my children, my legal representatives, my successors and my assigns. My signature verifies that I am physically fit to participate in yoga classes or Wildflower Healing sessions and/or events and a licensed medical doctor has verified my physical condition for participation in this type of class.

If I am pregnant or become pregnant or am post-natal, my signature verifies that I am participating in yoga classes with my doctor’s full approval. I realise that I am participating in yoga classes, healing sessions and/or events at my own risk.

The Health Waiver Agreement shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I acknowledge that the Health Waiver Agreement form will be used by the persons or entities being released in the Amore Tea, Wildflower Healing or Reiki Session(s) or Yoga classes or events and that it will govern my actions and responsibilities in said classes.
I hereby certify that I have read this document; and, I understand its content.

The fees paid by me under this enrolment to Amore Tea, Wildflower Healing Sessions or Yoga classes or events are non-refundable unless otherwise stated. Amore Tea may in its sole discretion grant refunds to me without prejudicing any of its rights.

I am aware that this is a release of liability as well as a contract and I sign it of my own free will. I also understand at the Amore Tea, Wildflower Healing Session or Yoga class or event or related activities, I may be photographed. I agree to allow my photo, video or film likeness to be used for any legitimate purposes by the Teacher/Practitioner or Amore Tea.

I hereby certify that I have read this document; and, I understand its content.I am aware that this is a release of liability as well as a contract and I sign it of my own free will.I have read COVIDSafe Agreement on the Amore Tea website at www.amoretea.com.au.

Signature*

Today's Date*

Date