Limitless Potentials & Dr. Kathryn Shafer
YogaFun™ For Ageless Living

Registration, Waiver of Liability, and HIPPA

I, (Your Name) HERE BY AGREE TO THE FOLLOWING:

I HERE BY AGREE TO THE FOLLOWING: Am aware that participation in psychotherapy, a workshop, or Yoga (sometimes called a sport, form of relaxation, or mindfulness exercise) can arouse emotional distress, pain, or injury, and by attending the client assumes the risk connected with the voluntary participation in these activities. I am aware this office is pet friendly, and you are accepting of this. I am also aware that participating by Zoom or telephone can involve internet difficulties which is not Dr. Shafer’s responsibility.

Voluntary or mandatory participation in psychotherapy, a workshop, or Yoga represents that you are in good physical health, and/or have obtained approval from a health care provider. This means that I have NO physical or emotional impairment which would limit my participation in these activities live in the office or by Zoom.

I also understand I will not cease any medical treatments or assume psychotherapy or yoga can replace such treatments or use of prescribed medications. I acknowledge that Dr. Shafer has not and will not render any medical services including a medical diagnosis of my physical condition or prescribe supplements. I specifically agree that Limitless Potentials, its psychotherapists, employees, and yoga instructors shall not be liable for any claim, demand, cause of action of any kind resulting from or related to the my participation in psychotherapy, a workshop, Yoga or Yoga Therapy, or any mindfulness exercise, and I agree to hold Limitless Potentials, Dr. Shafer and staff harmless from the same whether live or by Zoom.

I,(Your Name) have read the above release and waiver of liability and fully understand its contents.  I voluntarily agree to the terms and conditions stated above.

If participant is under 18:

As legal guardian of the participant, I consent to the above terms and conditions.

 

Please contact us with any health concerns or limitations.