Waiver & Release Form

Please make sure you have completed your booking before submitting this form. 

This form must be completed and submitted before attending your first movement or health coaching session. 

All information in this form will be treated as confidential.

Name *
Name
Phone *
Phone
Emergency Contact Number *
Emergency Contact Number
Date of Birth *
Date of Birth
Do you have any medical conditions, health issues or injuries that may affect your participation in movement or health coaching sessions? *
Women, are you currently pregnant or breastfeeding?
How would you describe your current level of movement or exercise?
SESSION/WORKSHOP AGREEMENT: *
I understand that movement sessions include physical movement, breathing and meditative practices, and that as part of my health coaching program I may be recommended the use of targeted supplement and nutritional protocols. Coaching sessions (movement or health-based) carry with them the risks usually associated with physical activity, including extreme fatigue, physical exhaustion, abnormal blood pressure, dehydration, fainting, dizziness, tripping, falling, hazards caused by other participants, heat, humidity, recurrence and exacerbation of existing or prior physical injuries or conditions, and adverse effects of medication, supplements or food. I am aware of the risks, dangers and hazards of the movement and health coaching sessions and I freely accept and assume all such risks, dangers and hazards and the possibility of personal injury, death, property damage or loss resulting therefrom.
*
I will take responsibility for my own health and safety and that of others when I am participating in movement sessions or following health recommendations supplied by Ke Ala. I will follow all instructions and directions by Ke Ala and its staff. I will keep Ke Ala and its staff informed and updated about my (my child’s) physical health and capacity to participate in strenuous exercise or follow health recommendations.
*
I release Ke Ala from or against any Liability to me for any Loss or Injury to me or any other person as a direct or indirect consequence of either movement or health coaching sessions or by me breaching the agreements above.
*
I indemnify Ke Ala from or against any Liability for any Loss or Injury to me or any other person as a direct or indirect consequence either movement or health coaching sessions or by me breaching the agreements above.
*
Photos may be taken during and after the sessions or workshops, either by Ross or Joelle Blake, or by a professional photographer. I understand that these photos may be used for promotional purposes by Ross or Joelle Blake (The Whole Mama). These photos are owned by Ke Ala with unrestricted use for whatever purpose.
I have read the above terms and accept these terms. The information provided in this form is true and correct. Submitting this form is considered my electronic signature.