Health Declaration and Waiver

Please fill out the following form.

In consideration of being allowed to participate in any way in the Pathways to Peace Yoga program, related events and activities, the undersigned acknowledges, appreciates and agrees to the following:

1. The risk of injury from activities involved in this program is significant, including the potential for permanent paralysis and death, and while

particular rules, equipment, and personal discipline may reduce the risk, the risk of serious injury does exist.

2. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releases or others, and assume full responsibility for my participation.

3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest

official immediately.

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release and hold harmless Pathways to Peace Yoga of Karen Gomez Wellness Consulting, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“Releases”), with respect to all and any injury, disability, death, or loss or damage to person or property, whether arising from the negligence of the releases or otherwise, to the fullest extent permitted by law.

This is to certify that I, do consent and agree to release, as provided above, of all the Releases, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releases from any and all liabilities incident to my involvement or participation in this program as provided above, even if arising from their negligence, to the fullest extent permitted by law.