Name: *

First Name

Last Name

Phone: *

(###)

###

####

Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you ever participated in any of the following? *

check all that apply

Yoga

Reiki

Sound Healing

Qi Gong

Other

Do you have any injuries or concerns that we should know about? *

medical history

Yes (please provide details below)

No, I do not have any injuries or concerns

TERMS & AGREEMENTS *

By completing this form, I hereby agree to the following Terms and Agreements: I am participating in any and all services with Vandana Taneja and/or Chakra Wellness including but not limited to Yoga, Reiki, Chakra Balancing, Sound Healing, Life Coaching, Qi Gong, Psychic Reading, House Blessing and do so with willingly of sound mind and body. I understand that if participating in Yoga, that I will receive information and instruction about the practice and I recognize that yoga requires physical exertion that may be strenuous and may cause injury. I am fully aware of the risks and hazards involved. I understand that the instructor may sometimes physically adjust a student during yoga classes/workshops. If I do not want such physical adjustments, I will inform the instructor at the beginning of each class or session. I understand that if participating in Reiki, that is a Japanese energy technique that is used for alleviating stress, pain management, stress reduction and deep relaxation and is not intended to cure or prevent any medical condition. I understand that participating in any of Chakra Wellness/Vandana Taneja's services, that she will not be diagnosing any conditions, prescribing or performing medical treatment, prescribing substances, or interfering with the treatment of a licensed medical professional. It understand that it is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that Yoga, Reiki, etc. can complement any medical or psychological care I may be receiving, however they are not in place of any medical treatment by a trained physician. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any of these services. I further understand that if I become pregnant it is my responsibility to inform the instructor and consult a physician prior to and regarding my participation in any of these services. I represent and warrant that I am physically fit and have no medical condition that would prevent my full participation in these services. In consideration of being permitted to participate in these services, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating. I knowingly, voluntarily and expressly waive any claim I may have against Vandana Taneja and/or Chakra Wellness instructors, agents, assistants, representatives for any injury or damages that I may sustain or as a result of participating in the service. I, my heirs or legal representatives forever release, waive, discharge and covenant not to sue Vandana Taneja and/or Chakra Wellness, instructors, agents, assistants, representatives for any injury or death caused by their negligence or other acts. Results may vary. Information and statements are for education only and not intended to replace the advice of your physician. Chakra Wellness/Vandana Taneja does not provide medical advice, prescribe treatments, mitigate, cure, prevent or diagnose illness. If you are experiencing a medical condition or health concern, be sure to consult with your healthcare provider.

I agree