Health Questionnaire & Waiver of Liability - Retreat

I agree that I am solely responsible for my own health and safety at all times during the Peace in Paradise Retreat in Bali, Indonesia from December 2-9th, 2017. Neither the facilitators nor Essential Yoga Studio, or Francesca ter Poorten shall be held liable for any injury related to this retreat. I agree to assume all risks associated with the program in any way. Furthermore, I also agree to inform the instructor of any movements which I cannot safely perform, and I will not perform any activity or movement, which I feel is likely to cause me to injure myself. I will inform the teachers and/or assistants of any limitations or medical conditions that may affect my practice. I agree to treat my body with patience, compassion and respect during my practice. I understand I can stop and rest at anytime.  I agree to release Essential Yoga Studio, Francesca ter Poorten and Retreat assistants from all liability for any injuries sustained as a result of my participation.  In consideration of being allowed to participate in any way in the yoga retreat, related events and Essential Yoga Studio activities, the undersigned acknowledges, appreciates, and agrees that:

  1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment and personal discipline may reduce this risk, the risk of serious injury does exist.
  2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation
  3. I willingly agree to comply with the stated and customary terms and conditions for participation. If however I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately.
  4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Essential Yoga Studio, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (“Releasees”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.

The risks include but are not limited to: natural forces from mother nature and mother earth which can result in obstacles and hazards; terrain; unstable governments; political upheavals; difficult communication as a result of lack of infrastructure or remote locations; extreme activities such as para-gliding, jet-skiing, or zip-lining; wild animals and insects; rapidly changing and extreme weather conditions; physical challenges; emotional challenges.   

Studio Parties while trained and qualified, have difficult jobs to perform.  While safety is a primary concern, Studio Parties may not be aware of all variables, including but not limited to a participant's fitness level, abilities, and other unknowns. 

In consideration of the services of the Studio and the Studio Parties, and in conjunction with the general waiver of liability (terms of use/refund policy), I hereby agree to the following:     

  1. The Studio will endeavour to satisfy all reasonable room accommodation requests from the Client but does not guarantee such requests will be met.  However, the Client will not be entitled to a refund if requests are not met.
  2. The Studio’s retreats may take place in remote areas or third world countries where there is little or no access to normal medical services or hospital facilities for serious problems. Medical and evacuation expenses will be the Client’s responsibility.  The Studio strongly encourages the Client to purchase travel insurance.  Additionally, the Studio reserves the right in its absolute discretion to refuse a Client the right to participate in any Program due to medical or fitness concerns.
  3. The Studio reserves the right to make changes to any aspect of the retreat if, in the absolute discretion of Studio, it is necessary to do so due to conditions that may be hazardous or dangerous or due to any other adverse or threatening conditions such as weather, government travel advisories, political, military, terrorist activities or for any other reason considered necessary by Studio.
  4. The Studio reserves the right to use photographs or videos for promotional purposes.  By making a reservation with the Studio, the Client agrees to allow its image to be used; however, if the Client appears in photographs and videos and prefers that items are not used, the Client must notify the Studio via e-mail before the retreat commences and the media will not be used.
  5. I acknowledge that my participation entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death or damage to myself, to property or to third parties.  I understand that such risks cannot be eliminated.
  6. I expressly agree and promise to accept and assume all of the risks existing in this activity.  My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.
  7. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless the Studio and Studio Parties from any and all claims, demands, or cause of action which are in any way connected with my participation in this activity or my use of the Studio's equipment or facilities including any such claims which allege negligent acts or omissions of the Studio.
  8. Should the Studio be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.
  9. I agree to bear the costs of any injury or damage I may cause or suffer while participating, or certify that I have adequate insurance to cover such costs.  I further certify that I am willing to assume the risk of any medical or physical condition I may have that may be aggravated or further exacerbated by the activity.
  10. In the event I file a lawsuit against the Studio, I agree to do so solely in the province of British Columbia and I further agree that the substantive law of that province shall apply in that action without regard to the conflict of law rules in that province.  I agree that if any portion of this agreement is found to be void or unenforceable, the remaining document shall remain in full force and effect.

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain  a lawsuit against the Studio on the basis of any claim from which I have released them herein. 

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Name *
Email *
Address *
Phone Number *
Date of Birth (YYYY-MM-DD) *
Health Care No. *
Emergency Contact Name *
Emergency Contact Email *
Emergency Contact Phone Number *
Emergency Contact Name *
Emergency Contact Email *
Emergency Contact Phone *
Please provide brief details of any known medical conditions (include medications, visual/hearing impairment, learning difficulties, etc.). Please advise if you have been under the care of a physician or health care professional (including mental health). Please advise if you have been hospitalized within the past year and if so, why. *
Do you use drugs (either prescribed or non-prescribed)? Provide details. *
Do you smoke? *
Do you drink alcohol? *
Do you have any challenges participating in physical activities? *
Do you have any current or past injuries? If so, please provide details. *
Do you have any special dietary requirements? If so, please provide details. *
Date (YYYY-MM-DD) *

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