VYAYAM's Enrollment Form for In-Person / Online SARVANG Yog (Mat Yoga / Chair Yoga) Classes - 2021
Please fill the form below.
Email address *
Your last name. *
If enrolling a child, please enter child's last name, otherwise say N/A (Please fill out a separate form for each child / each person in your household). *
Your first name. *
If enrolling a child, please enter child's first name, otherwise say N/A (Please fill out a separate form for each child / each person in your household). *
Participant's date of birth in mm/dd/yyyy format. (Please fill out a separate form for each child / each person in your household). *
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DD
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Participant's preferred pronoun *
Participant's street address. *
Participant's city. *
Participant's state. *
Participant's zip code. *
Participant's phone number *
Name of emergency contact *
Relationship with emergency contact *
Phone number of emergency contact *
Primary physician's name *
Primary physician's number *
Please list any physical conditions or health problems that may limit your yoga practice in VYAYAM's In-person / Online SARVANG Yog (mat yoga / chair yoga) classes : *
What is your objective in joining VYAYAM's In-person / Online SARVANG Yog classes? *
Please select all that apply. What is your preferred time for yoga practice through an online class ? (All times in Central Time Zone) You may indicate another option at the bottom, if you have a different time suggestion. You'll have to join in the Zoom meeting 10 minutes before the scheduled class time. *
Required
How did you hear about VYAYAM's In-person / Online SARVANG Yog classes ? Please list the name of your relative / friend / website, etc. who directed you to this program. *
If you're a past or current VYAYAM participant, please mention so. If a friend referred you, please list their name and email below for verification. If you got a direct email from VYAYAM, please list its subject and date for reference. If you saw this information on a website such as Facebook / Yelp / Google, please list the website and the link of the post below. Thank you for your attention to this.
Waiver of Liability, Affirmation, and Signature
Please read the liability waiver below, and enter your legal name underneath to indicate your agreement with the liability waiver as it appears below.
I, ____________________________________, hereby agree to the following: That I am participating in the yoga / pilates exercise classes offered by Vidya Nahar In-person / Online at VYAYAM, during which I will receive information and instruction about Mat Yoga, Chair Yoga, Pilates, Aerobics, Strength-Training, Relaxation, Pranayam (Breathing Techniques) and Laughter with or without using small appliances, including, but not limited to a yoga block, chair, dumbbells, stability ball, BOSU, pilates ring, foam roller. I recognize that these exercises require physical exertion, which may be strenuous and may cause physical injury, and am fully aware of the risks and hazards involved. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in above-mentioned exercises at VYAYAM through In-person / Online classes. In consideration of being permitted to participate in VYAYAM's In-person / Online classes, I knowingly and voluntarily and expressly waive any claim I may have against Vidya Nahar and / or VYAYAM for injury or damages that I may sustain as a result of participating in VYAYAM's In-person / Online classes. I, my heirs, and / or legal representatives forever release, waive, discharge and prospectively give up any right to institute any claim, suit or action against Vidya Nahar and / or VYAYAM for any injury or death caused by my participation in VYAYAM's In-person / Online classes. My prospective waiver and release shall apply to all claims and demands or causes of action including those that may arise out of the active / passive negligence of those hereby released. I have read the above release and waiver of liability form and fully understand its contents. I voluntarily agree to the terms and conditions mentioned above. I have received and read VYAYAM’s Payment Policy www.vyayam.com, and agree to abide by it. *
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Sign your full name below *
If registering a child, please enter child's full name below, otherwise say n/a (Please fill out a separate form for each child / each person in your household). *
Enter today's date *
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A copy of your responses will be emailed to the address you provided.
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