Class Waiver & Release Form

Name: ___________________________________ Age: ______Birth Date: ____/____/____

Address: __________________________________________________________________

City: _________________________________ Zip: _________Phone: _________________

Email: ________________________________________________________

Emergency Contact: __________________________________Phone:_________________

I understand that this class includes physical movements as well as an opportunity for personal growth, health education, and relief of stress. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor.  I assume full responsibility for any and all damages which may incur through participation.

Though Embodied Flow may be therapeutic in nature and offer relief to students, it is not a therapy group and no mental health issues will be assessed, diagnosed, or treated in this class. Embodied Flow is not a substitute for medical attention, examination, diagnosis or treatment. It is not recommended and is not safe under certain medical conditions. By signing, I affirm that a licensed physician has verified my good health and physical condition to participate in such a fitness program. In addition, I will make the instructor aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician's approval to participate. I also affirm that I alone am responsible to decide whether to participate and to do so is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Abisa Embodied Flow and its instructors.

I understand that instructor Lisa Elliott is a counselor-in-training at Antioch University Seattle, and that for part of each session she will be “shadowing” instructor Abby Kulkin (LMFTA), who is her supervisor for the psychoeducation and group processing part of this class. Abby will be utilizing her communication skills to engage the class and facilitate rich conversation among students but will not be functioning as a therapist in this class.

I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. I am signing this agreement voluntarily and recognize that my signature serves as complete and unconditional release of all liability to the greatest extent allowed by law in the State of Washington

Signature:                                                                                          Date:

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