Liability Waiver & Media Release

Full Name

Date of birth (YYYY-MM-DD)

Address

Instagram handle

Phone

Emergency Contact Name

Emergency Contact Relation

Emergency Contact Phone Number

Do you have any injuries or medical conditions? Include physical limitations that can be aggravated by exercise.

Choose several options

I represent and warrant that I am in good physical health and do not suffer from any medical condition which would limit my participation in pole fitness, yoga, sound healing, breath work, classes, workshops, retreats, jams, pole in the park, photoshoots, group activities, excursions or events offered via Polenomad, Kayla Woolbright and guest facilitators of Polenomad and Kayla Woolbright. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any pole fitness, yoga, sound healing, breath work, classes, workshops, retreats, jams, pole in the park, photoshoots, group activities, excursions or events. I understand the risks associated with the activities offered by Polenomad, Kayla Woolbright and guest facilitators of Polenomad and Kayla Woolbright and I agree to follow all instructions so that I may safely participate in pole fitness, yoga, sound healing, breath work, classes, workshops, retreats, jams, pole in the park, photoshoots, group activities, excursions or events hosted by Polenomad, Kayla Woolbright and guest facilitators of Polenomad and Kayla Woolbright. I hereby WAIVE AND RELEASE Polenomad, Kayla Woolbright and guest facilitators of Polenomad and Kayla Woolbright from any claim, demand, cause of action of any kind resulting from or related to my participation in pole fitness, yoga, sound healing, breath work, classes, workshops, retreats, jams, pole in the park, photoshoots, group activities, excursions or events. In taking part in pole fitness, yoga, sound healing, breath work, classes, workshops, retreats, jams, pole in the park, photoshoots, group activities, excursions or events offered by Polenomad, Kayla Woolbright and guest facilitators of Polenomad and Kayla Woolbright, I understand and acknowledge that I am fully responsible for any and all risks, injuries or damages, known or unknown, which might occur as a result of my participation. I have read the above release and waiver of liability and fully understand it's consent. I am legally competent to sign and voluntarily agree to the terms and conditions stated above. I am over the age of 18.

Choose several options

YES. I grant Polenomad, Kayla Woolbright and guest facilitators of Polenomad and Kayla Woolbright the right to take photographs and videos of me and my property in connection with the above mentioned subject. I authorize Polenomad and Kayla Woolbright to copyright, use and publish the same in print and/or electronically. I agree that Polenomad, Kayla Woolbright and guest facilitators of Polenomad and Kayla Woolbright may use such photographs and videos of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and web content. NO. I do not grant Polenomad, Kayla Woolbright and guest facilitators of Polenomad and Kayla Woolbright the right to take photographs of me and my property for any reason.

Signature (type full name)

Today’s date (YYYY-MM-DD)

Thank you for your response. ✨