Lupus Foundation of America, Indiana Chapter

We are devoted to solving the mystery of lupus, one of the world's cruelest, most unpredictable, and devastating diseases, while giving caring support to those who suffer from its brutal impact.

Yoga Registration - Lupus Patient

If you are a medical professional, nursing student, etc. and wish to receive approval to attend this class as a one-time-only guest, please call our office at 800.948.8806 or 317.225.4400 to receive approval and complete registration. Please do NOT complete this online registration form if you are not a lupus patient or caregiver/support person attending with a lupus patient.

1. PARTICIPANT INFORMATION: (You must be 16 or older to participate in this program. Participants under 18 must have parental consent.)

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Name:

 

 

 

     

 

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City/State/ZIP:

 

    

 

 

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Date of Birth:

 

 


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Question - Required - I agree to the following Participant Wavier (and Parental Consent if Participant 16-18 Years of Age)

 

By submitting this registration, I acknowledge on behalf of myself (and my child if I am submitting as a parent or guardian for a minor child) that each is a voluntary participant in this program and that I (or my child) could become ill or injured due to activity associated with this wellness program. I understand that I will receive information and instruction, including verbal and physical adjustment about yoga, tai chi and/or mindful meditation. In consideration of the privilege of being permitted to participate in this program, I, individually, (and, if applicable, for my child) and for my (or my child’s) personal representatives, heirs and assigns, do hereby:

  1. Release and forever discharge Lupus Foundation of America (LFA) and its Chapters, and their officers, employees and agents, including sponsors and all personnel involved in the program, from any and all claims liabilities whatsoever (including but not limited to, death, medical and hospital expenses), that I (or my child) might sustain as a result of participation in the event.
  2. Agree to indemnify and hold harmless LFA and its Chapters from all cost, expense and liability arising out of my or my child’s participation in this program.
  3. Waive all claims for damage or loss to me or my child’s person or property which may be caused by an act, or failure to act, by LFA or one of its Chapters, their officers, agents , volunteers, or employers arising directly or indirectly from my or my child’s participation in this program.
  4. Assume all liability for any injury, loss of life, or loss or damage to personal property from such event caused by myself (or my child).
  5. Grant irrevocable and full permission for the LFA and/or one or more of its Chapters to use my name and/or likeness in all media, including (but not limited to) photos, videos, film, web site or any other media or record of this event in which I may appear, for any purpose within LFA’s or any of its Chapter’s sole discretion. If you do not wish to be included in photos/videos, please let us know and though we cannot guarantee, we will make every effort to not include you in photos/videos.
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