Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

If at any time during the class you feel discomfort or strain, gently come out of the posture. You may rest at any time during class. It is important in yoga to listen to your body and respect its limits on any given day. *

I agree

I understand that yoga is not a substitute for medical attention, examination, diagnosis or treatment. I should consult a physician prior to beginning any activity program, including yoga. I recognize that it is my responsibility to notify my teacher of any serious illness or injury before every class. I will not perform any postures to the extent of pain or strain. *

I agree

I accept that neither the instructor nor the hosting facility is liable for any injury, or damages, to a person or property, resulting from the taking of the class. Those under 18 years of age must have this form signed by a parent or guardian. *

I agree

Signature *

First Name

Last Name

Date *

MM

DD

YYYY

Parent/Guardian Signature

required if applicant is under 18 years of age

First Name

Last Name

Date

MM

DD

YYYY