Gina DuBois

Release of Liability and Health Information

Due to the 2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each student. Please complete the following, read over the guidelines carefully, initial, and sign below.

Symptoms of COVID-19 include, but are not limited to:

  • Fever or chills
  • Cough
  • Shortness of breath or difficulty breathing
  • Fatigue
  • Muscle or body aches
  • Headache
  • New loss of taste or smell
  • Sore throat
  • Congestion or runny nose
  • Nausea or vomiting
  • Diarrhea

Symptoms may appear 2-14 days after exposure to the virus.

Please read and initial the following statements:

I am in good health & not experiencing any of the above symptoms.

I have not been exposed to COVID-19 in the last 14 days.

I have NOT been outside of the State of NY in the last 14 days (prior to class date).


If yes, please explain the dates, whether you traveled by air, and any other relevant details. This may require you to wait 14 days after travel to attend in-studio yoga classes.

I have not shown any symptoms of COVID-19 in the last 14 days (prior to service).  


  • Because of the small size of the studio and the nature of yoga for deep, heavy breathing, it is imperative to know that the students in the studio are not ill. Since a fever over 99 is indicative of COVID-19 your temperature will be checked upon entry. Anyone with a temperature over 99. will not be permitted in the studio for class.
  • You are required to wear a mask upon arrival, set up, and departure. Once you are on your mat you DO NOT have to practice with your mask on. However, if you leave your mat (to use the bathroom or for any other reason) you are required to put your mask back on.
  • Shoes removed at door. All purses, jackets places in designated spaces.
  • You are required to wash hands or use hand sanitizer upon arrival.
  • You are required to use only the marked-out spaces for mat placement. If you do not adhere to the marked spaces, you will be asked to leave.
  • It is recommended for students to bring their own class supplies which might include a yoga mat, 2 blocks, strap, yoga blanket, bolster. The studio will provide you props if needed however, all used supplies are to be returned to the designated area to be sanitized before returning to shelves. DO NOT PLACE BACK ON THE SHELVES.

Your yoga instructor Hidden Haven Yoga, dba Gina DuBois Yoga, reserves the right to cancel/reschedule your yoga class if you do not adhere to the above guidelines or are exhibiting signs of COVID-19.

I hereby understand all requirements and will fully abide by all of them.

Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: Release of Liability and Health Information
lock iconUnique Document ID: c5782b35a19cf42a545cea97e095615b87820f2c
Timestamp Audit
June 29, 2020 3:20 pm EDTRelease of Liability and Health Information Uploaded by Gina DuBois - IP