Consent and Health Declaration

Please fill out the following health declaration form in order to participate in our activity. Submissions are valid up to 24 hours prior to the activity.

First Name

Last Name

______1. I am voluntarily participating in classes or services during which I will receive information and instruction about meditation. I further recognize and understand that the instructions and advice presented to me during the coaching are in no way intended as substitutes for medical and/or other professional counseling. If I have any health concerns that may interfere with my participation in the coaching, I understand that I should consult my healthcare provider before beginning the meditation exercises. ______2. I recognize that the Serenity Experience may involve physical movement, such as sitting, standing and walking meditation. I represent and warrant that I have no physical or mental health condition that would prevent my safe participation in Serenity Insight’s meditation classes. ______3. In consideration of being permitted to participate in Serenity Insight’s meditation classes, I agree to assume full responsibility for any risks, injuries or damages, known and unknown, which I might incur as a result of participating in the program. If I experience pain or difficulty that is cause for concern during or after practicing the meditation exercises, I understand that I should stop immediately and consult my healthcare provider before continuing on with the meditation exercises. ______4. In further consideration of being permitted to participate in the meditation classes, I knowingly, voluntarily, and expressly waive any claim I may have against Serenity Insight, the class instructor, the owner, or the leaseholder of the building for injuries or damages that I may sustain as a result of participating in classes or sessions held at Serenity Insight. I have read the above release and waiver of liability and fully understand its contents. By checking this box, I voluntarily agree to the terms and conditions stated above.

If your appointment is in person, are you experiencing any flu symptoms?

Yes

Date

Electronic Signature

I confirm that the information given in this form is true

Thanks for submitting!