Liability Waiver Form

Please fill out all fields marked with a " * "

First Name

Last Name

Phone Number

Emergency Contact (Name and Phone Number)

Do you have any medical problems, physical limitations, injuries or chronic illness?

I understand and confirm that Nia is a strenuous physical activity and that my participation in Nia by Nia Diva classes is voluntary and entirely at my own risk.

Yes

I understand and confirm that I should regularly inform my Nia teacher Alice Francillon, owner of Nia Diva, of any new medical problems, physical limitations, injuries and chronic illness occurring.

Yes

I understand and confirm to knowing that Covid 19 is a contagious virus and there is a risk of contracting it by participating in a Nia Diva Class. In the event that I contract Covid 19 or any other condition while participating in a Nia Diva class I assume full responsibility and hold Nia Diva harmless. Further I agree to not attend class if I have any signs or symptoms of Covid 19.

Yes

I release Nia Technique, Nia Diva, Alice Francillon and/or any Nia teachers working with or for Alice Francillon of any responsibilities for any consequences arising from the activity of my participation in Nia Diva Classes.

Yes

I understand and agree that by signing this Nia Diva Liability waiver, I confirm that I have carefully read and fully understood its content.

Yes

Have you done Nia before?

Yes

Where?

When?

For How Long?

How did you hear about Nia by Nia Diva classes?

Why are you interested in stepping into a Nia practice?

Signature and date

Please type in your full name and the current date to certify that all the above information is accurate.

Full Name

Date