Release Form: Liability Release: I Acknowledge and Fully Understand That I And/or My Child Will Be Engaging in Physical

Release Form
Parent/Guardian Full Name: _________________________________________________________

Childs Full Name: __________________________________________ M/F: ________________
Birthdate: ______________________ Age: __________ Grade/Teacher:____________________
Address:____________________________________________________________________________
City: ___________________________________ State: __________________ Zip: ______________
Home Phone: _____________ Cell Phone: ____________Email: ___________________________
Emergency Contact Name: ______________________________Relationship:________________
Emergency Contact Phone: _________________________________________________________
Doctors Name: _______________________________ Doctors Contact Phone: _____________
Known Allergies/Physical Limitations/Concerns/Goals:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I individually and also as parent and/or guardian of the minor child identified above hereby acknowledge
the following notices and grant to Grounded Kids, LLC the following release from liability and
negligence:
Liability Release: I acknowledge and fully understand that I and/or my child will be engaging in physical
activities that may involve risk of injury. I acknowledge that I have been advised to consult with my or
my childs physician with respect to any past or present injury, illness, health problem or any other
condition or medication that may affect my and/or my childs participation in this yoga program. I assume
the foregoing risks and accept personal responsibility for any and all personal injury sustained by my
child and/or myself and discharge and hold harmless Grounded Kids, LLC, its owners, directors,
members, officers, teachers, employees, and agents from any claim, cause of action or liability for
damages arising from any injury to my childs person, my person, or other persons or property caused by
my or my childs participation in Grounded Kids yoga program including the negligence of Grounded
Kids LLC.
In the event that I/or my child become ill or injured during or as a result of participation in the class, I
hereby allow Grounded Kids, LLC to arrange for such emergency medical attention as they in their sole
judgment may deem to be required to preserve my life and /or my childs life and/or health. I hereby
release, discharge, and hold harmless Grounded Kids LLC, as well as any person or entity that provides
such emergency medical attention, from any and all liability in connection with any injury to my property
arising in connection with or as a result of such emergency medical treatment.
Parent/Guardian Signature: _______________________________Date: _______
Media Release: I have been informed and agree to the following: that photographs/videos may be taken
of my participation and /or the participation of any minor of whom I am guardian, in Grounded Kids LLC
programs and classes. I hereby grant Grounded Kids, LLC, the right to use such videos, photographs, and
/or parts of photographs in its promotional materials, without any compensation being paid to me on my
own behalf, or on behalf of any minor of whom I am guardian. Further, such usage may be a part of any
media either now extant, or developed in the future, and such usage may be engaged in without any
further permission being given from Grounded Kids, LLC. It is understood that no personal names shall
be associated with the images used.
Parent/Guardian Signature: _______________________________Date: ________

Release Form: Liability Release: I Acknowledge and Fully Understand That I And/or My Child Will Be Engaging in Physical

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Parent/Guardian Full Name: _________________________________________________________

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