Registration/Liability 
 
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***PLEASE LIST ALL PAST OR PRESENT INJURIES, PHYSICAL LIMITATIONS AND ANY PERTINENT ILLNESSES ON BACK OF FORM

STUDENT REGISTRATION/CONSENT/LIABILITY WAIVER

FOR PARTICIPATION IN YOGA CLASS, WORKSHOP, EVENT, OR ACTIVITY

 

Please fill out this form and hand in to your yoga teacher. (Please print)

 

Circle class registering for:   Special Event/Workshop -  _________________________________________

 

Gentle - Monday  /  Multi Level 1 - Thursday 7:45 / Multi Level 2 - Thursday 6:15 /  Intermediate - Monday

 

Last name: __________________________________ First name: _________________________________

Address: ____________________________________________ City: ______________________________

Province: _____________ Postal Code ____________________ Birthdate: D_______/M_______/Y_______

Email Address:__________________________________________________________________________

Phone: Home: ___________________________ Cell: _____________________ _____________________

Emergency contact: __________________________________________ Phone: ______________________

If under 18 -  Name of Parent(s)/Legal Guardian(s): ______________________________________________

 

NOTICE:

Any sport or yoga can be a physically demanding activity. It is vitally important that you are in a physical condition that will allow you to participate without presenting a danger to yourself or others. If you have any concerns that a health condition, injury or previous lack of physical activity may put you at risk of personal injury or discomfort, please advise your yoga teacher. Before participating in this or any exercise program, individuals should consult with a physician.

 

Individuals under eighteen (18) years of age must have written consent/permission of their parent(s) or legal guardian(s).

 

VOLUNTARY PARTICIPATION

I, the undersigned, acknowledge that I have voluntarily chosen and requested to participate in the yoga class, workshop, event, or activity (hereinafter referred to as yoga class) sponsored by Carol Wallace.

 

ACKNOWLEDGEMENT

I am aware that participation in any sport or in yoga may result in accident or injury, and I assume the risk connected with the participation in a sport, in yoga, or in activities related to the instruction of yoga and I represent that I am in good health and suffer from no physical impairment which would limit my participation in the yoga class.  I acknowledge that Carol Wallace has not and will not render any medical services, including medical diagnosis of my condition.

 

RELEASE

In consideration for being permitted to participate in the yoga class, I agree that I, my heirs, assignees, guardians, and legal representatives will not make any claim against, sue, or attach the property of, any of the hosts, teachers, organizers, or participants in the yoga class, including but not limited to Carol Wallace, her assistants and agents for injury or damage resulting from my participation in such yoga class. I release all such hosts, teachers, organizers, and participants, their agents and heirs, from any and all actions, causes of action, lawsuits, claims or demands that I, my assignees, heirs, guardians, and legal representatives now have or hereafter may have for any and all injury, illness, death, loss of or damage to property associated with my participation in the yoga class.

 

I have carefully read this agreement and fully understand its contents. I have signed this release freely and voluntarily. I am aware and agree that it is a complete release of liability for any injuries or damages I may sustain due to my participation in yoga classes, workshops, events and activities with Carol Wallace, her assistants and agents.

 

Note:  If you are under the age of 18 years, your parent(s) or legal guardian(s) must sign on your behalf.

 

Dated at Moose Jaw, Saskatchewan, this ____________ day of ____________________________, 201____

 
 


_________________________________________ 

Signature: 

 

Yoga in Moose Jaw