COVID Release Form

Dear Yoga Lova student

In order to comply with government regulations and for both your safety and our own please complete this form ONLINE prior to EACH AND EVERY VISIT at Yoga Lova. If you do not complete this form online, you will be required to hand in a hard copy of this form at the front desk, prior to allowing access to the studio.

Date of visit*

First Name*

Last Name*

Email*

Phone*

Have you or anyone in your family recently had any of the following symptoms. Fever, cough, sore throat, shortness of breath?*

Yes
No

Have you or anyone in your family had body aches, loss of smell or taste, nausea, diarrhea, fatigue,weakness or tiredness?*

Yes
No

Have you or anyone in your family been in contact or the immediate vicinity with anyone that has tested positive OR awaiting results for COVID-19? (Within the past 14 days)*

Yes
No

Anything else you would like to add?

I further agree to all the terms below and if required will notify of any changes and give full consent with regard to this form and the declaration below.

I AGREE to notify Yoga Lova (by email to nadine@yoga-lova.com) of any change in status, including diagnosis with Coronavirus and/or quarantine, within thirty (30) days either before or following a visit to the studio.

I WILL, if asked, wear a mask (of the specifications recommended by any Yoga Lova staff) at all times while visiting the studio, and will take all reasonable prophylactic steps that may be recommended by Yoga Lova, staff and/or any relevant authority.

I WILL consent to having my temperature taken by any representative or agent of the building or staff, during, and after any visit, and will provide any follow up information reasonably requested by Yoga Lova.

I ACKNOWLEDGE and ACCEPT that this Declaration shall be governed by the laws of South Africa. I irrevocably agree that the competent Courts of South Africa shall have jurisdiction to hear and determine any suit, action or proceeding, and to settle any dispute which may arise out of, under, or in connection with this Declaration and for such purposes hereby irrevocably submit to the jurisdiction of such Courts. Nothing contained herein shall limit the right of Yoga Lova to take proceedings in any other Court of competent jurisdiction nor shall the taking of proceedings in one or more jurisdiction preclude the taking of proceedings in any other jurisdiction whether concurrently or not.

I ACKNOWLEDGE and ACCEPT that this Declaration will be considered as my consent to Yoga Lova to disclose, share, record and store this Declaration with any relevant authority or service provider for the purposes of ensuring the safety and security of any and all third parties that may come in contact with me prior, during, and after any visit.

Phone

This field is for validation purposes and should be left unchanged.

covid release form

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