Release Form – Yoga for Kids of CNY

Parent/Guardian Full Name:

Child’s Full Name

Birthday

Boy/Girl/Non-binary

Age

Grade/Teacher

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email Address

Cell Phone

Home Phone

Emergency Contact Name + Relationship

Doctor’s Name:

Emergency Contact Phone:

Doctor’s Contact Phone

Known Allergies/Physical Limitations/Concerns/Goals:

How did you hear about this class? (copy)

I individually and also as parent and/or guardian of the minor child identified above hereby acknowledge the following notices and grant to Julie Daniel of Yoga for Kids of CNY the following release from liability and negligence: Liability Release: I acknowledge and fully understand that I and/or my child will be engaging in physical activities that may involve risk of injury. I acknowledge that I have been advised to consult with my or my child's physician with respect to any past or present injury, illness, health problem or any other condition or medication that may affect my and/or my child's participation in this yoga program. I assume the foregoing risks and accept personal responsibility for any and all personal injury sustained by my child and/or myself and discharge and hold harmless Julie Daniel of Yoga for Kids of CNY, its owners, directors, members, officers, teachers, employees, and agents from any claim, cause of action or liability for damages arising from any injury to my child's person, my person, or other persons or property caused by my or my child's participation in Yoga for Kids of CNY yoga program including the negligence of Julie Daniel of Yoga for Kids of CNY. In the event that I/or my child become ill or injured during or as a result of participation in the class, I hereby allow Julie Daniel of Yoga for Kids of CNY to arrange for such emergency medical attention as they in their sole judgment may deem to be required to preserve my life and /or my child's life and/or health. I hereby release, discharge, and hold harmless Julie Daniel of Yoga for Kids of CNY, as well as any person or entity that provides such emergency medical attention, from any and all liability in connection with any injury to my property arising in connection with or as a result of such emergency medical treatment.

By checking this box and signing below I understand the paragraph above

Signature

Clear Signature

Date

Media Release: I have been informed and agree to the following: that photographs/videos may be taken of my participation and /or the participation of any minor of whom I am guardian, in Yoga for Kids of CNY programs and classes. I hereby grant Julie Daniel of Yoga for Kids of CNY, the right to use such videos, photographs, and /or parts of photographs in its promotional materials, without any compensation being paid to me on my own behalf, or on behalf of any minor of whom I am guardian. Further, such usage may be a part of any media either now extant, or developed in the future, and such usage may be engaged in without any further permission being given from Julie Daniel of Yoga for Kids of CNY. It is understood that no personal names shall be associated with the images used.

Yes
No

Signature for Media Release

Clear Signature

Date for Media Release

Yoga for Kids of CNY Release Form