Yoga Registration Form: Yoga Registration Form:
CLASS: (circle) Parent/Tot PS/Kind After-school Family Yoga
Child's name:__________________________________________________________________
Girl_________Boy________Date of Birth:_____________________Age:__________________
Parents: ______________________________________________________________________
Address______________________________________________________________________
Home #____________________________________Cell#_______________________________
Work#________________________________________________________________________
E-mail_________________________________________________________________________
Emergency Contact: Name/Number___________________________________________________
DoctorName/Number_____________________________________________________________
Please list ALL known allergies, physical limitations or concerns________________________
Goal/s of taking these classes:_____________________________________________________
Drop in: __________________date:________________________________________________
1 month class card:
start date__________________________expiration_____________________________
Liability Disclaimer & Notices:
I___________________________________________the parent/guardian of the above mentioned child
hereby acknowledge the following notices and grant to Jeanette Runnings and Gilbert Yoga the following release from liability:
A. My child will be engaging in physical activities that may involve some risk of injury.
B. I have been advised to consult my or my child's physician with respect to any past or present injury, illness,
health problem or any other condition or medication that may affect my or my child's participation. I assume the
foregoing risks and accept full personal responsibility for any personal injuries sustained by me or my child which
might incur as a result of participation in this program and discharge and hold harmless Jeanette Runnings and Gilbert
Yoga from any claim, cause of action or liability for damages arising from any personal injury to my child or other persons
or property caused by myself or my child's participation in the program.
C. I clearly understand that there are no refunds, but punch card can be transferred to a friend or relative of my choosing
if I am unable to attend. In cases of severe medical reasons or extenuating circumstances an extension may be granted as
determined by instructor.
D. I agree/disagree to give permission for Jeanette Runnings to photograph and use my child's picture/s for promotional purposes.
I understand that my child will not be identified by name without my permission, nor will any compensation be extended for such use.
Parent/Guardian Signature_________________________________________________________
Date:__________________________________________________________________________