In consideration of being allowed to participate in Provita session(s) and related events and activities, the undersigned acknowledges, appreciates, and agrees that:

1) I, the undersigned, being aware of my own health and physical condition, and having knowledge that my participation in a Provita session may cause injury, am voluntarily choosing to participate in the program. There are always certain risks associated with any physical activity. I understand these risks and declare myself physically sound and capable to participate in a Provita session.  The risk of injury from the activities involved in this session may be significant, while specific instructions, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,

2) I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,

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 to the professional trainer or teacher immediately; and,

4) I, for myself and on behalf of assigns, my heirs, and personal representatives, HEREBY RELEASE AND HOLD HARMLESS Provita, their officers, officials, agents, other participants, sponsoring agencies, sponsors, and if applicable, owners and lessors of premises used to conduct the event (“RELEASEES”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I have read this document in its entirety, fully understand its terms, and understand that I am giving up substantial rights – including my right to sue. I know, understand and appreciate these and other risks that are inherent in the Activity. I expressly agree and assert that participation in the Activity is voluntary and I knowingly assume all such risks and elect to proceed with the participation despite all the risks. I acknowledge that I am signing this document freely and voluntarily and intend, by my signature, the complete and unconditional release of all liability to the greatest extent allowed by law.



Name (required) :
Address (required) :

Is the address provided the location of your session? If not, please identify the desired location for your session. (required) :
Phone Number (required) :
Emergency contact name and phone number (required) :
Age - How old are you? :
Weight - How much do you weigh? :
Height - How tall are you? :
Please inform us of any current or recurring injuries or strains. :
Medical History - please check any true statements (If any are checked, please consult with your physician before exercising.) :
  •  Have you had any heart complications (Heart failure, attack, disease, transplant, pacemaker)?
  •  Do you have diabetes?
  •  Do you have asthma or lung disease?
  •  Are you pregnant?
  •  Do you experience chest discomfort with physical exertion? Unreasonable breathlessness? Dizziness, fainting, or blackouts?
Cardiovascular Risk Factors - please check any true statements (if two or more statements are checked, please consult with your physician before exercising.) :
  •  Are you a man over 45 yrs old? Or a woman over 55 yrs old?
  •  Do you smoke? Or have quit smoking in the last 6 months?
  •  Do you have high blood pressure / high cholesterol levels?
  •  Do you get less than 30 mins of exercise at least three times a week?
  •  Are you 20 lbs overweight?
Are you comfortable with hands-on adjustments? :
Are you on any medication or prescription drugs? If so, which ones? :
If you are booked for a yoga session, do you require our Pro to bring a yoga mat, blocks, or straps for your session? :
Have you ever had a private yoga, fitness or wellness session? If so, please send any details that you remember. :
Please be aware that our Pros are equipped with safety and security tools for everyone's protection. Please identify if there is a doorman or front desk at your location and if there will be any other people present during the session. :
Please provide us with any requests or further information so we can best prepare for your session. :
Your signature (required) :
How did you hear about us? :
  •  Online
  •  Social Network
  •  Friends
  •  Other