Group Services

First Name *

Last Name *

Date of birth *

Phone Number *

Email *

Are you interested in being contacted about individual, couples, and/or family therapy services? *

Yes

Primary Insurance Provider *

Primary Insurance Subscribers Name *

Primary Subscriber Date of Birth *

Primary Insurance Member ID *

Upload Insurance Card Option

Which Group are you interested in? *

I, the undersigned participant, acknowledge and agree to the following:

Voluntary Participation I am voluntarily participating in yoga classes, workshops, or other yoga-related activities offered by Healing Solutions Family Therapy Center and its instructors, volunteers, and organizers.

Assumption of Risk I understand that participating in yoga may involve physical exertion and carries inherent risks, including but not limited to muscle strain, sprains, broken bones, or other injuries. I am fully aware of these risks and voluntarily assume full responsibility for any injuries, damages, or losses I may incur as a result of my participation.

Health Warranty I represent that I am physically fit and have no medical condition that would prevent my full participation in these Activities. I understand it is my responsibility to consult with a physician prior to and regarding my participation in the Activities.

Release and Waiver of Liability In consideration for being permitted to participate in the Activities, I, on behalf of myself, do hereby release, waive, discharge, and covenant not to sue the Organizers from any and all liability, claims, demands, actions, or causes of action arising out of or related to any loss, damage, or injury, including death, that I may sustain while participating in the Activities.

Severability If any provision of this waiver is found to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

I have read and fully understand this waiver and release of liability. I sign it voluntarily and understand that I am giving up substantial legal rights.

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