The Vine Studio

Student Liability Waiver

The Vine Studio Student Liability Waiver
Check boxes if you agree (3rd Box must be checked to submit the form):

Please be aware of your body during class. Let us know what medical problems you may have, including but not limited to heart trouble, diabetes, hypoglycemia, asthma, lower back pain, high or low blood pressure. If you have had recent surgery, or are pregnant, you should not participate without a written consent from your doctor.


By submitting this waiver, I acknowledge that I should inform each instructor of any physical limitations, problems or conditions that would adversely affect my ability to participate in any exercise without further injury. I will abide by my instructor’s decision regarding my participation. I agree to inform the instructor of any injury or unusual pain that occurs during or shortly after the class. I understand that in any program of exercise, there is some risk of injury, despite the best efforts of the instructors, and I am willing to assume all risks.


By submitting this form, I hereby release (for myself, my heirs, my executors and administrators) Nia® Technique Inc., Nia® Instructors, other class instructors, The Vine Studio Board and The Vine United Methodist Church from all claims, liabilities, expenses or judgments arising out of my participation in classes or workshops.  This liability waiver applies to all claims, liabilities, expenses or judgments for any injuries, ailments or illnesses (including but not limited to Coronavirus).    


I have carefully read and understand the foregoing provisions. By submitting this form, I hereby certify and acknowledge that I understand all the terms of this contract and agree to be legally bound by the terms and conditions.

Call:  704-858-0379


2101 Belvedere Avenue, Charlotte, NC  28205

Room 302 of Education Building at The Vine United Methodist Church

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