SHAKTI HEALING CIRCLE LLC

LIABILITY WAIVER

To sign-up for Body Lab, EMA, Qi Gong, or Special Workshop classes with Rie Katagiri please fill out the following form:

First Name

Email Address

Last Name

Date of Birth

Assumption of Risk: I agree to assume unconditionally full responsibility for any and all inherent risks, injuries or damages, known or unknown, which I may incur as a result of my participating in class.

Yes

I understand that it is my responsibility to consult with a physician prior to and regarding my participation. I understand that I must use my own discretion when performing any postures, work at my own level and explore my own limits. I further understand that my participation does not constitute or replace the advice or treatment of a medical professional.

Yes

To the fullest extent allowed by law, & on behalf of myself & associates, I/we hereby release Shakti Healing Circle LLC, Erotic Movement Arts, & affiliated persons, from any & all responsibility or legal liability for any injuries, damages to me or to any other person, whether resulting from negligence or any other cause related to arising from my participation in any class/related activity.

Yes

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

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SHAKTI HEALING CIRCLE LLC LIABILITY WAIVER

SHAKTI HEALING CIRCLE LLC

LIABILITY WAIVER