STUDENT APPLICATION AND HOLD HARMLESS AGREEMENT
First Name ________________ Last Name __________________________
Mailing Address ________________________________________________
City ______________________ State ________________ Zip __________
Phone ___________________ Work Phone __________________________
DOB __________ E-Mail_________________________________________
How did you hear abut us? ☐ Internet ☐ Mail ☐ Walk/Drive By ☐ Other Who referred you? __________________________________________________________
Yoga Experience: ☐ Beginner (0-6mo) ☐ Intermediate (6mo-2yrs) ☐ Advanced (3+ yr)
Check Weekly Exercise Frequency: ☐ 0 ☐ 1-2 times ☐ 3-4 times ☐ 5+ times
Explain (use other side of form if necessary) any recent of current medical condition or limitation you have & furnish a letter from your physician authorizing Yoga or stating exercise limitations. ☐ None or ________________________________________________________________
In consideration of and as an inducement to my enrollment and payment of fees to become a student of Sculpt Yoga (hereinafter “SY”), I represent and agree as follows:
(1) I have been examined by a licensed Physician within the past six months and have been found by such physician to be in good health and fully able to perform all yoga exercise, which I am to learn and perform during my enrollment with SY. (2) I will faithfully follow all instructions given to me by SY authorized instructors as to when and how to perform and not to perform yoga exercises. I understand the practice of yoga and group exercise activities may expose me to risk of injury, disease, or death and I knowingly and willingly assume such risk.
(3) I understand and agree that I will receive instruction in yoga theory and exercise only and that I hold harmless SY, it’s employees, officers, directors, and contract trainers for any damage to or theft of personal property on or away from SY premises, or personal injury, including but not limited to bodily injury, disease, disability, death, humiliation of consequential loss of any kind arising out of my participation in any SY event.
(4) In the event that I am pregnant, I will not attend a yoga class until I have discussed the potential risks to me and my unborn child with my obstetrician. I agree to follow all recommendations and on behalf of myself, my heirs, spouse or other interested party hold harmless SY for any possible injury to myself of my unborn child.
(5) If I am under 18 years of age, I warrant that I have disclosed my age to SY and in addition to my signature, have provided the signature of my parent or legal custodian or guardian below.
(6) Registration fees and Tuition for classes pair hereafter are non refundable.
Date ___________ Signature ____________________________
Print Name ___________________________________________
Parent of legal guardian signature (if under 18 yrs of age)
Phone Number of parent or legal guardian