Christian Yoga Studio

 

Name

First  __________________________             Last  _____________________

 

Home Phone             _______________                          Cell Phone _________________

 

Address

Street ____________________             City             _______________State             _______

 

Zip Code___________

 

Email ___________________________________

 

 

Referred By_________________________________

 

 

Emergency Contact

Name ____________________Relationship_____________

 

Emergency Phone___________________________________

 

 

Do you have any physical limitations of which we should be aware?

 

 

 

IN CONSIDERATION OF being permitted to participate in the Activity, the undersigned, on behalf of myself and my heirs, executors, administrators and assigns, hereby:

 

1.             Release and forever discharge the Sponsor and its employees, officers, directors, shareholders, affiliates, agents, representatives, successors and assigns (collectively the “Releasees”) of and from all claims, demands, damages, costs, expenses, actions and causes of action (collectively the “Claims”) in respect of death, injury, loss or damage to myself or property howsoever caused, arising or to arise by reason of or during my participation and/or involvement in the Activity, and notwithstanding that any Claim may have been contributed to or occasioned by the negligence of any of the Releasees.

 

2.             Indemnify and, including reimbursement of all sponsor’s attorney’s fees and court costs, save harmless the Releasees from and against any and all liability incurred by any or all of them arising as a result of or in any way connected to my participation in the Activity.

 

3.             Understands and acknowledges that the Sponsor does not carry or maintain health, medical or disability insurance coverage for the undersigned and therefore agrees to assume responsibility for such insurance coverage on the undersigned.

 

4.             Agrees that in the event that any provision of this Release and Indemnity is held to be invalid or unenforceable by any court of competent jurisdiction, the invalidity or unenforceability of such provision will not affect the remaining provisions of this Release and Indemnity which shall continue to be enforceable.

 

I HEREBY ACKNOWLEDGE READING, UNDERSTANDING AND AGREEING WITH THE FOREGOING.

 

 

Signature             ___________________________             Date____________

 

Witness Signature______________________ Date____________                                                                                                                     

 

 

 

Payment is due with waiver and registration in order to secure your spot in class.