Please provide any and all details about your past health history, including past injuries, surgeries, or illnesses.
Please explain your current health and wellbeing needs with regards to starting a yoga therapy program with Hersha.
If you have any physical limitations, use mobility aids or experience differences in your intellectual functioning, please provide details here:
Terms & Conditions *
By participating in the services offered by Hersha Yoga / Evantis Wellness, I hereby agree to the following:
My participation may include physical movement, breathing, meditation and other related practices. I am fully aware of the risks (including physical injury) involved and assume full responsibility for any risks, injuries or damages which I might incur as a result of participation.
It is my responsibility to consult with a medical professional prior to and regarding my participation in the program. I understand that these services are not substitutes for medical attention, diagnosis or treatment, and under certain conditions, these services are not recommended.
I agree to exercise sensible caution for my own well-being, while participating under any circumstances (whether indoors or at an exterior location). I am responsible for my own personal property.
I fully acknowledge my limitations. It is my decision to pursue a particular technique.
I voluntarily and expressly waive any claim I may have against Hersha Yoga, Evantis Wellness, any staff, assisting staff and lecturers, sponsors of event, affiliate organisation or participating locations for injury or damages that I may sustain as a result of my participation.
I forever release, waive, discharge and covenant not to sue for any injury or death caused by my negligence or other acts.
I grant Hersha Yoga, Evantis Wellness its representative and employees the right to take photographs or videos of me and my property in connection with the above-identified subject.
I authorise Hersha Yoga / Evantis Wellness, its assigns and transferees to copyright, use and publish the same in print and/or electronically.
I agree that Hersha Yoga / Evantis Wellness may use such photographs or video of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and web content.
I agree to pay the full fee and understand the Cancellation Policy:
Cancellations made 30 days or less prior to the program start date incurs 10% administrative fee and any online charges through third party organisation.
Cancellations made 10 days or less prior to the program start date incurs 20% administrative fee and any online charges through third party organisation.
No refunds will be issued to participants after the program/training begins.
In the case of a medical emergency, Hersha Yoga / Evantis Wellness will retain the balance without interest and the sum can be applied to retaking the teacher training program upon recovery or used towards other programs/trainings hosted by Hersha Yoga / Evantis Wellness. If not applied within one year, all monies paid shall be forfeited.
I have read the above release and waiver of liability and fully understand its contents and I voluntarily agree to the terms and conditions stated above.
Typing my name below confirms my agreement:
Please explain your reasons or current health situation which has led you to seek Yoga Therapy? What do you hope to address?
