Rohilia & Back 2 Basics
Yoga and Dance Class Registration Form
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NOTE: This is only a registration. Your program will be confirmed only once payment is received in full. After you complete this form, the teacher will contact you to answer any questions and help you complete your booking if needed.; @eccentricexperientialist
Back 2 Basics; @Xiomara.Ospinar
This program is in person for 2.5 hours.
DEADLINE to register is OCTOBER 20, 2023.
First and last name *
Age *
Residential address zip code
Mobile number *
Email address *
Program(s) you would be interested to attend or learn more about: *
Emergency contact name, relationship and phone number *
How did you come to know about this class? *
What are the main reasons you want to attend this class?  *
Please indicate below if you have any physical challenges or currently or previously have had any physical or mental ailments (such as hernia, neck or back disease, dislocations, joint replacements, injury, depression, anxiety etc.). Please give details of the nature and duration of the condition and if you are currently undergoing any treatment. If none, please state so. *
For women, are you currently pregnant? *
(If you stated you are pregnant in the previous question) How many months have you been pregnant? *
Have you had any major surgery in the last six months? *
Did you have any symptoms of COVID-19 in the past 14 days or have you been diagnosed or treated for the same within the past 30 days? *
Please use one of the links below to pay for the program you are attending. Please note: in order not to loose this spot to another participant, once the class is confirmed/paid for, there will be no refunds. Rescheduling the class is only at the teacher's discretion and schedule and will include a make-up fee of at least $100. Same day cancelations/no-shows will not be refunded nor will the class be rescheduled.
I agree to indemnify and hold the program teacher/volunteers/employees/guests of Rohilia and Back 2 Basics harmless with respect to any bodily injury, my health, ailments (including Covid-19 ), or recovery during my participation in the program. They shall not be liable and do not hold any responsibility for the same. I hereby willingly undertake to attend this program completely. I take full responsibility for the results and risks and indemnify the organizers against all claims and suits. I will not communicate the contents of the program, either directly or indirectly to anyone else. I understand the participation guidelines and agree to follow them. I hereby declare that the above information is true, accurate and complete to the best of my knowledge.
Date *
Signature - please type your full name *
Thank you for choosing Rohilia and Back 2 Basics! Follow us on Instagram @eccentricexperientialist and @xiomara.ospinar 🙏🏻 .
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