waiver

By signing this form I agree not to hold Jennifer Polyocan liable for any injury or communicable disease ex. covid19 that may incur during your lesson with Jennifer. This is for online lessons and in person lessons. You will not hold her responsible and this releases her from any legal obligations.

Please fill out the following form.

First name

Last name

Email

Date of birth

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

If you answered yes to any of the questions above, please supply additional information.

Initials

I declare that the info I’ve provided is accurate and complete.

waiver

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