Name *

First Name

Last Name

Phone *

(###)

###

####

Do you have any injuries, prior surgeries, or medical conditions which may impact your ability to participate in breath work and movement?

Yes

No

I give consent and choose to participate in the practice of breath & movement for my own benefit. I assume responsibility to participate in ways that are best for me to get the most out of this practice. I have stated all known medical conditions, and will update the teacher (Lauren) of any changes. I understand breath & movement is not a substitute for medical treatment. I release the teacher (Lauren) from all liability while practicing breath & movement with me. (If I have any questions whether this practice is right for me I will consult my healthcare provider prior to class.)

I agree

I disagree