Client Intake Name * First Name Last Name Email * Phone * (###) ### #### Mailing Address * Date of Birth * Occupation * Have you done embodiment work / personal training before? Yes No What are your goals for embodiment sessions? * Please describe any injuries (past or present) that could impact our time together? * Please check off any condition below that applies to you: Anxiety Depression DVT/Blood clots Artificial Joint Diabetes Osteoporosis Heart Condition Recent Surgery Epilepsy/seizures Headaches/migraines High or low blood pressure Circulatory issues Numbness Pregnancy Arthritis Please explain any condition you checked above Is there anything else about your health history that you think would be useful for me to know? AGREEMENT OF RELEASE AND WAIVER OF LIABILITY FORM Why You’re Reading This Document The purpose of this release and waiver (the “Waiver”) is to openly communicate the risks of practicing movement together, either in person or online, and have you release Abby Puente and Embody with Abby of any liability. Please be aware that if you do not sign this Waiver and agree to its terms, you will be unable to participate in my classes. PLEASE READ CAREFULLY, UNDERSTAND FULLY, AND ASK QUESTIONS IF ANYTHING IS UNCLEAR. WE ARE HERE TO SUPPORT YOU. MAKE SURE YOU UNDERSTAND THIS WAIVER. BY SIGNING THIS YOU AGREE YOU ARE SIGNING AWAY YOUR LEGAL RIGHTS AND YOU AGREE TO BE BOUND BY ALL THE TERMS OF THIS AGREEMENT. 1. Parties. We will refer to Abby Puente as Embody with Abby, a partnership registered in the State of California, as “Embody with Abby”, “I” or “me” and we’ll refer to you, the undersigned (electronically or by hand) or person who has clicked “I Agree” to this Waiver, as “you” or “your”. 2. The Activities. You will be participating in movement and exercise classes with Embody with Abby. I offer movement classes that may involve but are not limited to the following activities (the “Activities”): a. During class we will practice sequences of movement that build strength and mobility, and may involve breathing exercises, functional movement, self massage, and meditation. b. The Activities also apply to any exercise classes which are made available for online streaming and participation. As these classes will be taking place without in-person guidance by me, you acknowledge that you are responsible for the safe facilitation of the Activities. 3. Equipment. In the course of the Activities, you may use a variety of equipment (the “Equipment”), which may include but is not limited to: yoga blocks, bolsters, straps, mats, resistance bands, pillows, dumbbells, kettlebells, foam rollers, massage balls. Please do not use any equipment not instructed by us. 4. Inherent Risks. You understand that participating in the Activities poses inherent risks, some more obvious/serious than others. These risks can result in serious harm and injuries that could change your quality of life and, in very rare and extreme circumstances, may even result in death. a. Injuries include but are not limited to things like muscle tears, strains and other musculoskeletal injuries, sprains, broken bones, cardiovascular complications, dehydration, dizziness and fainting. b. Exposure to and contraction of COVID-19 or other communicable diseases passed on via other participants and use of shared space or Equipment. c. There are additional risks posed by participating in the Activities online, as there is no in-person supervision or space provided for you, and you will therefore need to ensure the safety of the Activities, using your judgment how to best practice them, not pushing yourself too far or attempting anything you feel unsure how to perform. d. There are additional risks posed by using Protective Gear while exercising and performing the Activities, including but not limited to asphyxiation, respiratory and breathing difficulty, chest pain, fainting, fatigue and collapse. 5. Affirmation of Health. By participating in any Activities with Embody with Abby, you affirm that you have sought medical advice regarding your fitness to practice. If you have not sought such advice, you must be certain that your medical and fitness levels are sufficient to participate in functional fitness, yoga, and Pilates based classes. 6. Voluntary Assumption of Risk. You have read this Waiver and understand the risks of participating in the Activities with Embody with Abby. Your signature below, electronic signature or clicking 'I Agree’, and your participation in the classes at Embody with Abby illustrates your voluntary participation and assumption of the risks of the Activities. 7. Release, Waiver and Indemnity. You hereby release Abby Puente and Embody with Abby, its members, directors, officers, contractors, employees, volunteers, agents, executors, administrators, successors, family members and assigns (the “Released Parties”) from any liability and damages arising from death or personal injuries, including the contraction of COVID-19 or other communicable diseases, however caused including as a result of Embody with Abby's negligence, during your participation in the Activities with Embody with Abby. You are releasing the Released Parties at your own risk and you agree to forfeit any and all forms of legal recourse which may be available to you, including but not limited to any form of damages, as a result of your participation in the Activities. You agree that these provisions above apply to you, your family, heirs, executors or anyone else who may be able to bring a legal action on your behalf in the future. 8. Media Release. By being a student with me in-person or online, you agree to grant me the irrevocable right to use your image, likeness, photographs, video content, audio recordings of you captured in my studio or that you share with me online (via your own or others posting of you) as part of my online streaming, marketing and sales throughout the world and in perpetuity. You also release me from all claims you may have relating to the use mentioned in this section. Please let me know If you ever want us to stop using an image of you. 9. General Legal Provisions. Jurisdiction. This Waiver will be governed exclusively by the laws of the State of California. Severability. If any provisions of this Waiver are invalid or unenforceable, the other provisions in the Waiver will remain in full force and effect. Entire Agreement. This Waiver constitutes the entire agreement between the parties and replaces any prior agreements. Headings. The headings used in this Waiver are for stylistic purposes only and none of the content in the headings are intended to be legally binding. Online Agreement. We agree that this Agreement may be signed electronically or agreed to by having you click “I Agree”, the effect of which will be the same as if we signed the Agreement by hand and the intention of which is that both parties desire to be bound by all the terms of the Agreement. You agree that you have read this Waiver and fully understand its contents and voluntarily agree to be bound to all of its terms. Thank you for your cooperation! I look forward to enjoying movement together. CLIENT SIGNATURE (Type Full Name) * Date * MM DD YYYY Thank you!
