Effective Date: 1 July 2026
This Medical Indemnity Form forms part of the agreement between Parimukti Yoga and Meditation Private Limited (“Parimukti”) and the participant. Completion of this form is mandatory before participation in any retreat, Somatic Facilitator Training, workshop, or other programme requiring physical activity, breathwork, meditation, somatic practices, or emotionally intensive processes.
Participant Details
Full Name
Date of Birth
Email Address
Emergency Contact Name
Relationship
Emergency Contact Telephone
Medical Disclosure
Please answer every question honestly and completely.
Have you ever been diagnosed with, treated for, or are you currently experiencing any of the following?
□ Heart disease
□ High blood pressure
□ Low blood pressure
□ Stroke
□ Respiratory disease or asthma
□ Epilepsy or seizures
□ Diabetes
□ Recent surgery
□ Serious injury
□ Pregnancy
□ Chronic pain condition
□ Severe allergies
□ Psychiatric illness
□ Psychosis
□ Bipolar disorder
□ Severe anxiety
□ Severe depression
□ Panic disorder
□ Current suicidal thoughts
□ Any condition requiring regular medication
□ Any other physical or psychological condition that may affect safe participation
If you answered “Yes” to any question above, please provide details:
Medications
Please list any medications you currently take which could affect participation.
Allergies
Please list any allergies, including food allergies.
Medical Clearance
If Parimukti reasonably believes additional medical information is required before participation, I agree to provide written medical clearance from an appropriately qualified healthcare professional before attending.
I understand that failure to provide requested medical information may result in my participation being postponed or declined.
Participant Acknowledgements
I understand that the Programme may include:
- yoga;
- breathwork;
- meditation;
- somatic exercises;
- movement;
- partner exercises;
- emotional release practices;
- periods of silence;
- group sharing;
- and other physically or emotionally demanding activities.
I acknowledge that these activities carry inherent physical and psychological risks.
I confirm that:
- I have disclosed all relevant medical information honestly and completely.
- I will immediately inform Parimukti if my medical condition changes before or during the Programme.
- I will not participate beyond my own physical or emotional limits.
- I understand that participation is voluntary.
- I remain responsible for deciding whether to continue any activity.
Medical Treatment
If I become ill or injured during the Programme and I am unable to make decisions for myself, I authorise Parimukti to arrange emergency medical treatment where reasonably necessary.
I understand that all medical costs, hospital expenses, medications, ambulance charges, evacuation expenses, and related costs remain my own responsibility.
Assumption of Risk
I understand that participation may involve risks including, but not limited to:
- physical injury;
- muscle strain;
- dizziness;
- emotional distress;
- aggravation of existing medical conditions;
- travel-related accidents;
- illness;
- and other unforeseen events.
I voluntarily assume these risks.
Release and Indemnity
To the fullest extent permitted by applicable law, I release and hold harmless Parimukti Yoga and Meditation Private Limited, its directors, facilitators, employees, contractors, volunteers, and agents from claims arising from my voluntary participation, except to the extent caused by gross negligence, wilful misconduct, or liability that cannot legally be excluded.
Nothing in this form excludes any rights that cannot lawfully be waived under applicable law.
Declaration
I declare that:
- the information contained in this form is true and complete;
- I have carefully read and understood this Medical Indemnity Form;
- I understand the nature of the activities offered by Parimukti;
- I voluntarily agree to participate subject to the Terms & Conditions and associated policies.
Participant Name
Signature
Date