Children's Waiver Ages 4–12

Yoga, Mindfulness & Breathwork Waiver

Child's First name

Last name

Parent/Guardian First and Last Name

Parent/Guardian Email

Phone

Child's Birthday

Month

Day

Year

Address

List 2 Emergency Contacts:

Name & relationship to Participant:

Phone

Name & relationship to Participant:

Phone

Children's Yoga, Mindfulness & Breathwork Waiver

(Ages 4–12)

Program(s): Kids Yoga • Mindfulness • Breathwork • AcroYoga/Partner Work • Various Yoga Styles & Techniques

Purpose

This waiver explains the activities offered to children ages 4–12 and obtains your informed consent for participation. It includes age-appropriate breathwork, mindfulness, yoga postures, physical energy release like walking/light cardio, games, mindful arts and crafts, and optional acroyoga/partner work. Please read carefully and initial or check where indicated.

Health Disclosure (Parent/Guardian to complete)

My child is in good health and can participate in light-to-moderate physical activity with no special adaptations.

If no, please explain and list any provisions needed:

Initial:

My child has the following relevant injuries, allergies, learning or behavioral needs (attention, sensory, ASD/ADHD, etc.), or other medical conditions I should be aware of:

I agree to update the instructor on relevant health information changes.

Initial:

Nature of Activities & Age-Appropriate Modifications

Activities may include: warm-ups: walking/light cardio to warm muscles and release built-up energy, appropriate yoga postures (standing, seated, balancing), partner or group games, mindfulness, relaxation, guided imagery, and age-appropriate breathwork (e.g., belly breathing, bee breath, lengthened exhale).

Children will not be taught long breath holds, forceful hyperventilation, or advanced breath retentions.

AcroYoga/partner work (if offered) is optional, beginner-friendly, and supervised with spotting and safety cues; a child may opt out at any time.

I understand that instructors will adapt to the attention span typical of ages 4–12 (e.g., short segments, playful transitions) and may adjust class times, pacing, and activities to keep children engaged and safe.

Initial:

Clothing and Footwear Policy

For everyone’s comfort, safety, and ability to participate fully in class, we ask that all students follow our clothing guidelines:

• Please wear comfortable, flexible clothing that allows free movement.

• Skirts and dresses are not permitted during class for safety and mobility.

• If you need to wear something on your feet while doing yoga, grip socks, sneakers with traction, or yoga shoes are allowed.

• Crocs, sandals, flip-flops, or non-grip socks may not be worn during class.

• We recommend clothing that covers you appropriately during stretches, bending, and inversions.

✅ DO wear:

• Comfy clothes you can stretch in (leggings, shorts, sweatpants, T-shirts)

• Grip socks or yoga shoes if you need something on your feet

🚫 DON’T wear:

• Skirts or dresses (hard to move and keep covered, or safe in poses)

• Crocs, sandals, flip-flops

• Socks and shoes without grip (they can be slippery)

Why?

We want you to be safe, comfy, and able to move without slipping or tripping!

Initials:

Appropriate, Optional Hands-On Adjustments

Instructors may offer brief, appropriate hands-on assists solely for stability, alignment, or safety (e.g., steadying a shoulder, guiding a foot placement). Touch is always optional and explained in kid-friendly language.

I consent to appropriate, professional hands-on adjustments for safety and stability.

YES/NO

Initial:

Assumption of Risk & Release

I understand that yoga and related activities carry inherent risks, including, but not limited to, minor strains, falls, bumps, dizziness (especially during balance or breathwork), and, rarely, more serious injury. By signing, I voluntarily assume all risks for my child’s participation and agree that A Space to Exhale, its owners, instructors, assistants, contractors, venue partners, and affiliates are released and held harmless from any claims or liabilities arising from participation, except in cases of gross negligence or willful misconduct.

Initial:

Supervision, Drop-Off/Pick-Up, and Personal Items

I understand supervision is provided only during scheduled class times. I am responsible for the timely drop-off and pick-up of my child’s items. Space to Exhale, its owners, instructors, assistants, contractors, venue partners, and affiliates, for lost or damaged belongings.

Initial:

Illness & Participation

My child will not attend if experiencing fever, vomiting, contagious illness, or symptoms that could compromise their safety or the safety of others. Instructors may ask a child to rest or sit out if unwell, overly fatigued, or not following safety directions.

Initial:

Emergency Medical Care Authorization

In the event of an emergency and if I cannot be reached, I authorize the service provider(s) to obtain necessary medical treatment for my child. I accept responsibility for any related costs.

Initial:

Photography/ Videography Media Release (Optional)

I grant permission for photos/video of my child to be captured for ONLY yourself and your child to have of them in class

YES/NO

Initial:

I grant permission for photos/videos of my child to be captured during classes or sessions and used for program materials, social media, and websites. If “Yes,” I understand that names and/or faces will not be posted without separate written consent and your prior review of the content. I am an influencer with four children. When they are posted, it is done so in a discreet, purposeful way. I understand any personal concerns you may have about this issue, so I will always protect your child’s identity and respect both of your wishes regarding the matter. You will be emailed a separate media waiver with the content to approve if your child is posted online in any way.

YES/NO

Initial:

Child-Friendly Code of Conduct

I will try my best.

Be nice to others.

Listen to my teachers, parents, and helpers

Try new things and be brave.

Be kind with my words and actions.

Have fun and help others have fun, too.

Always be respectful to people, the props/surroundings, and the spaces we are in.

(Teachers will review these themes in each class in a friendly, supportive way to encourage them to practice this part of yoga even outside class.

Parent/Guardian Acknowledgments

Please check each statement:

I have read and understand the Nature of Activities & Age-Appropriate Modifications section.

I have disclosed relevant health information and will update as needed.

I understand and agree to the clothing and footwear policy.

I understand hands-on assists are optional, and I’ve indicated my preference above.

I accept the Assumption of Risk & Release terms. is a checkbox.

I authorize Emergency Medical Care if needed.

I have stated my Media Release preference.

Signatures

Parent/Guardian Name (print):

Parent/Guardian Signature:

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Instructor/Company Contracted For Guiding Session(s):

A Space to Exhale/Kia Monet Yoga

Instructor: Kia Monet Keller, 800-Hour Certified Yoga & Meditation Instructor

Phone: 513-202-3634

Email: kiamonet@aspacetoexhale.com

Website: www.aspacetoexhale.com