GrassRootsYoga
New Student Registration ~ please print and bring to class
Name Telephone
Address
e-mail (secure)
Date of Birth
Emergency Contact
How did you hear about GrassRootsYoga?
Health Issues, injuries, special needs:
Interested in:
Release and Waiver of Liability Agreement
I agree to the following:
1. That I am participating in yoga classes and events offered by GrassRootsYoga and Latitude during which I will receive information and instruction about yoga and health. I recognize that yoga requires physical exertion that may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.
2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in yoga classes, on-site events, or workshops. I represent and warrant that I am sufficiently fit and healthy and have no medical condition that would prevent my full participation in yoga classes, events or workshops at 167 Saunier Street, Lexington, Kentucky, GrassRootsYoga and Latitude.
3. I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the program.
4. I, my heirs, or legal representatives forever release all liability regarding all of the above. I voluntarily and expressly waive any claim I may have against my yoga instructor, GrassRoots Yoga, or Latitude for injury or damages that I may sustain as a result of participating in the program.
5. I voluntarily agree to all terms and conditions as stated.
__________________________________________________ Date_________________
Signature of Participant or Legal Guardian
