QUESTIONAIRE AND AGREEMENT OF RELEASE & WAIVER OF LIABILITY FOR MELINDA JANOFSKY-YOGA TEACHER 

GENERAL INFORMATION 

SPORTS/MEDICAL HISTORY

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Are you affected by any of the following (check all that apply)

RELEASE & WAIVER OF LIABILITY 

I agree to the following:

  1. The information I have provided above is complete and accurate.

  2. Assumption of Risk. (yoga/fitness conditioning) I understand that I am participating in yoga/fitness conditioning sessions by Melinda Janofsky, during which I will receive instruction about yoga, fitness, health, and wellness. I recognize that yoga/fitness conditioning requires physical exertion that can be strenuous. I am fully aware of the risks involved, including the risk of serious injury, including permanent disability and death, and other losses, both to person and property.  I assume all risks, known and unknown, in any way connected with my participation in the yoga/fitness conditioning sessions.   I accept personal responsibility for any liability, injury, loss, or damaged in any way connected with my participation in such activities.

  3. Assumption of Risk.  (health coaching) I consent to participate voluntarily in a  health coaching program with Melinda Janofsky (hereinafter “Program”) and  I  recognize this  Program may contain certain inherent risks.     I expressly assume the risks of the  Program and  I take full responsibility for my life and well-being and all decisions made before,  during, and after the  Program. I understand that the information provided at or in conjunction with the  Program, including dietary recommendations and/or supplement advice, is not intended to be a  substitute for professional medical advice, diagnosis, or treatment that can be provided by my physician,  therapist,  licensed dietitian or nutritionist,  or any other licensed or registered health care professional.   I understand that the health coaching  I receive in the Program is not from medical or mental health care providers, that I am not receiving health care,  medical, or nutrition therapy services, and the Program is not attempting to diagnose,  treat or cure in any manner whatsoever,  any disease,  condition or another physical or mental ailment of the human body. Rather, the Program is serving only in the capacity of a coach,  educator,  mentor, and guide. I agree to seek the advice of my physician or another qualified health care professional prior to and during the Program regarding any questions or concerns  I  have about my specific health situation,  possible or actual pregnancy,  known or suspected food sensitivities or allergies,  dietary restrictions,  or any medications  I  am currently taking.    I  agree to not disregard professional medical advice or delay seeking professional advice or stop taking any medications without speaking to my physician or health care professional. I understand that no claim is made as to the certain efficacy of any nutritional or supplement protocols. Additionally,  I  understand that this program may also include recommendations in regards to bringing balance to the physical, emotional, mental, and spiritual components of my being. I  understand that adopting any of these recommendations is voluntary and by choice.  I fully understand that all lifestyle recommendations, including but not limited to physical exercise and food are designed with my health,  well-being, and utmost safety in mind.   I have been informed and understand physical exercise and food modifications have been associated with certain risks,  including but not limited to, musculoskeletal injury,  spinal injuries,  abnormal blood pressure responses, respiratory distress,  and in rare instances heart attack or death.  In the event that I may injure myself or become ill as a  result of my participation in this program, I hereby release, discharge,  and waive any and all liability,  damages,  causes of action,  allegations,  suits,  sums of money,  claims, and demands which  I  have ever had,  now have,  and could have in the future arising from my participation in anything related to the  Program,  now or in the future.

  4.  Waiver and Release. I waive, release, and hold harmless Melinda Janofsky, her sponsors, employees, volunteers, agents, successors, and assigns from all claims for any liability, injury, loss, or damaged in any way connected with my participation in such yoga/fitness conditioning/health coaching activities.

  5. Consultation with Physician. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in yoga/fitness conditioning/health coaching activities.

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