Waiver and Release

Before taking classes or workshops at Embrace Self Wellness, or receiving massage or ayurvedic wellness services, all adult students and parents/guardians of kids under 18 must agree to the following Waiver and Release Agreement. Please complete the form at the bottom of this page to submit your electronic signature.

 

Waiver and Release Agreement

As the student taking classes or workshops, or client receiving massage or ayurvedic wellness services at Embrace Self Wellness (ESW), I understand that ESW classes, workshops & services can include physical movements and exertion. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in ESW classes or services. I represent and warrant that I am in good health and physical condition and I have no medical condition which would prevent my full participation in ESW classes or services. In addition, I will make the instructor/practitioner aware of any medical conditions or physical limitations before my class or service. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature below verifies that I have my physician’s approval to participate. In consideration of being permitted to participate in ESW classes or services, 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 the program.  In further consideration of being permitted to participate in ESW classes or services, I expressly irrevocably release and waive any claims that I have now or may have hereafter for any reason against Embrace Self Wellness, its owners, employees and independent contractors, for injury or damages that I may sustain as a result of participating in a ESW class or service.

Consent for Treatment: I have been informed and hereby understand that Kyanne Kerbel is not a trained in western medical diagnosis or treatments. She is not a physician, nor licensed to practice western medicine. Kyanne has fulfilled the highest and most rigorous standards prescribed by National Certification Board of Therapeutic Massage, and is licensed nationally as a Board Certified massage and bodywork therapist.. Kyanne has completed a 250hr. Yoga Teacher Training, and is recognized as a Certified Yoga Teacher and Yoga Wellness Coach through the teachings of James Miller's Adamantine Yoga. She has continued her yoga training to extend into Yin & Restorative Yoga certifications. Kyanne has studied the teaching of Maya Tiwari, at the Wise Earth School of Ayurveda and has completed her certification focus in Women's Health and Spirituality. Kyanne Kerbel, and Embrace Self Wellness, cannot alter medications. If you decide to use herbs or supplements, you must seek approval from your doctor. Kyanne Kerbel, and Embrace Self Wellness, holds no liability for any herbs, oils, or supplements and any reactions that they may cause.  If you are suffering from a disease or severe symptoms, you must be evaluated by a medical doctor. If you choose not to see a medical doctor, you will have to sign this acknowledgement that one was recommended to you.

For Parents Registering Children for Kids Classes, Workshops, or Service: I am the parent and/or guardian of the minor child/children for whom I am registering. I have read this release and permission and fully understand its contents, and I have the full right and authority to execute this release and permission.

Photos: I may be photographed during yoga classes, workshops or treatments and these photographs may appear in Embrace Self Wellness promotional materials unless otherwise specified. No person whose photograph is used will be identified by name, nor will any compensation be extended for such use.

Name *
Name
Release of Liability Electronic Authorization
Health History *
Electrionic Signature: *
Electrionic Signature:
By typing in my FIRST and LAST name I am hereby approving this Release of Liability and a

.