Release of Liability

Name

First

Last

Phone

Address

City

State/Province

Zip/Postal

Country

Please list any health-related conditions that you have or have had that could affect your ability to participate in class, including but not limited to surgeries, joint replacements, fusions, joint pain, auto-immune disorders, cancer, pregnancy, muscle, tendon or bone injury, and any chronic pain.

If none, type “none”

am aware of my own health and physical condition.

1) I certify that my participation in MELT and/or AMBA MOVEMENT is a potentially hazardous activity. I have been informed of and understand and am aware, that any exercise and/or fitness activities involve a risk of injury, and that I am voluntarily participating in these activities with understanding and appreciation of the risks involved. I hereby agree to expressly assume and accept any and all risks of injury regardless of severity.

I agree

I disagree

2) I understand that all information and services provided by [you or your company] are of a general nature and are provided for educational purposes only. None of the information or services provided by [you or your company] are to be taken as medical or other health advice pertaining to any specific health or medical condition that I have or may have had. The information and services provided by [you or your company] are not a diagnosis, treatment plan or recommendation for a particular course of action regarding my health and are not intended to provide specific medical advice.

I agree

I disagree

3) I understand that I am learning MELT and/or AMBA MOVEMENT techniques for my own self-care and I can not teach any MELT and/or AMBA MOVEMENT techniques to any other group or population in a class setting until appropriately trained and licensed by Longevity Fitness or (in the case of AMBA MOVEMENT) by AMBA founder and creator Meghan Makena. I understand that there are potential legal consequences for teaching this material directly or by teaching the techniques and calling it by another name.

I agree

I disagree

General Photography Release

I hereby authorize [you or your company] to publish photographs taken of me at any MELT and/or AMBA MOVEMENT class or workshop, and my likeness, for use in [you or your company] or MELT’s and/or AMBA MOVEMENT’S print and online marketing materials.

I hereby release and hold harmless Ellen Katharine Embodiment from any reasonable expectation of privacy or confidentiality associated with the images specified above. I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type for these photographs.

e-Signature (Type your full name)

Clear

reCAPTCHA

If you are human, leave this field blank.