Cultivate Yoga Release Form

Participant Name *
Participant Name
Birthday *
Emergency Contact Info
Contact Name *
Contact Name
Contact Phone *
Contact Phone
Optional Medical Information
Please list any medical conditions, health concerns or physical limitations you would like Cultivate Yoga to be aware of
Accept *
By checking this box and submitting this form, I am accepting all TERMS & CONDITIONS listed below
Date of Acceptence *
Date of Acceptence
Consent for Child
Name of Legal Guardian
Name of Legal Guardian
As the legal guardian of the participant listed above I am accepting all TERMS & CONDITIONS listed below for said participant by checking this box and submitting this form
Date of Consent
Date of Consent


I understand there is inherent risk associated with any exercise program including my voluntary participation in yoga or fitness that may result in injury.  I understand and am aware that the components of exercise/yoga are potentially hazardous.

I acknowledge that I have either had a physical examination and/or have been given permission from my physician to participate in an exercise program or that I have decided to participate in an exercise  program voluntarily without the approval of my physician and hereby assume all responsibility for my participation in any exercise/yoga associated with Cultivate Yoga.

My legal representation waives and releases Cultivate Yoga owners, board members, employees and any teachers/instructors from any and all liability and responsibility from injury, accident, illness, legal and medical fees sustained now or in the future resulting from my participation in any activity.

I acknowledge that Cultivate Yoga is recognized as a 501(c)(3), non-profit organization at the federal and state (Ohio) levels.  Any donations made by me to Cultivate Yoga are considered Tax-Deductible and  will be routed to the organization, it’s representatives (including teachers/instructors) and/or the Cleveland regional community at the discretion of Cultivate Yoga’s board members.

I have read this waiver/liability form.  I fully understand its terms and conditions.