TIMBo Intake Form and Waiver

Welcome! Thanks for taking the time to fill out this form. It really helps me to know a bit about you and how I can best serve you.

Name

First Name

Last Name

Email Address

Phone

(###)

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Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

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Medical Information

Please give me a sense of your general health and physical capabilities so that I can instruct you to the best of my ability.

Injuries and Dates

Recent Surgeries and Dates

Physical Limitations

Chronic Conditions

Areas of tension or pain

Other Pertinent Information

Have you done yoga before?

If yes, for how long?

General Guidelines for Practicing Yoga

Listen and follow all instructions carefully. Ask the instructor if you are unsure how to perform a movement. Breathe smoothly and continuously as you move; do not hold your breath. Work gently, respecting your body’s abilities and limits; do not strain. Don’t perform movements that are painful. If you experience sharp shooting pain, come out of the posture at once.

Acknowledge

Click the box below to acknowledge that you have read and understand the above guidelines and that you recognize that these guidelines can help reduce your risk of injury.

I acknowledge the guidelines.

Release & Waiver of Liability

Please read carefully! This is a legal document, which affects your legal rights! In exchange for participation in TIMBo with Mary Beth Thomas and Tara McLinden, I agree voluntarily and without duress to the following: 1. WAIVER AND RELEASE I do hereby release and forever discharge and hold harmless Mary Beth Thomas, Tara McLinden, and mbt yoga from any and all liability, claims and demands of whatever kind of nature, either in law or in equity, which arises or may hereafter arise from participation in TIMBo. I understand that this Release discharges Mary Beth Thomas, Tara McLinden and mbt yoga from any liability or claim that I may have against Mary Beth Thomas, Tara McLinden and mbt yoga with respect to any bodily injury, illness, emotional or psychological harm that may result from participation in TIMBo even if caused by the negligence of Mary Beth Thomas, Tara Mc Linden or mbt yoga. I also understand that Mary Beth Thomas, Tara Mclinden and mbt yoga does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health or disability insurance, in the event of injury or illness. 2. ASSUMPTION OF THE RISK I understand that TIMBo is a psychologically rigorous journey towards healing. I am responsible for my experience in the TIMBo program and for my own well being during and after the sessions. I understand the practice of yoga, self- inquiry and mindfulness often produces non-ordinary states of awareness and that Mary Beth Thomas, Tara McLinden and mbt yoga are not responsible for my personal experience. I understand that practicing yoga, mindfulness and exercises of self inquiry is often about exploring new boundaries and personal limitations. I recognize that activities of this nature involve an element of physical, emotional, and psychological risk. I understand each person's level of physical and psychological fitness is different, and each group participant will progress in the program at their own self monitored pace. I accept the need to monitor my own participation and that Mary Beth Thomas, Tara McLinden and mbt yoga are not responsible for any physical and psychological risk I choose to take in my education, exploration, and inquiry. I understand that my attendance at group is important if I want to complete the program and that my participation is never required if I feel unsafe in any way. lt is my responsibility to honor my physical and psychological boundaries, and if I feel unsafe in anyway, to stop participation in an experience and speak to Mary Beth Thomas or Tara McLinden immediately. 3. OTHER I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Michigan, and that this Release shall be governed by and interpreted in accordance with the laws of the State of Michigan. I agree that in the event that any clause or provision of this Release shall be held to be invalid by a court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release which shall continue to be enforceable.

Agree to Release and Waiver of Liability

By selecting the box below and typing your name, you are agreeing to the above stated release and waiver of liability.

I agree to the release and liability waiver.

First and Last Name

Today's Date

YYYY