Level One Registration Form
Thank you for your interest in our training program!

Please complete the form below to register for Level One training at Breakaway Yoga in Baltimore, MD on February 21-23, 2020. Once you have completed this form, you will receive an email with instructions on how to complete your sign up and payment for the program. Your email will be sent to the email you use on this form.

Please allow 3 business days to receive your welcome email. The email will come from info@polliwogkidsyoga.com. If you do not receive an email within one week of your registration, please email us to inquire.

We look forward to learning and leading with you!

-The Polliwog Kids Yoga Family
Name *
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Email *
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Phone number *
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How did you hear about this training? *
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T-Shirt Size *
What do you hope to get out of this training? *
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Medical Information
Do you have any allergies? If yes, please list. If no, please write "None" in the box. *
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Do you have any medical conditions that are important for us to know about? If yes, please list. If no, please write "None" in the box. *
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Emergency Contact Name *
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Emergency Contact Relation *
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Emergency Contact Phone Number *
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Waiver of Liability
Please read our general waiver of liability below prior to continuing. Please note this includes information about minor children because it is our general waiver of liability and is not specific to this training only.

I acknowledge that I understand that yoga is a physical activity and I am a voluntary participant. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I assume full responsibility for any and all risks, injuries or damages, which may incur through my participation or participation of my minor child(-ren), if applicable, in yoga or any other related instruction with BJ Hart, Courtney Hart or any other instructors of Healing Hart Wellness, LLC/Polliwog Kids Yoga.

I affirm that I understand that it is my responsibility to consult with a physician prior to and regarding my participation, or the participation of my minor child(-ren), in any yoga session. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I agree to make the instructor aware of any medical conditions or physical limitations of myself, or my minor child(-ren) before any instruction occurs.

I agree to follow all instructions and pay attention to my own body, discontinuing activity if I begin to experience discomfort or pain. I will also make sure that my minor child(-ren) understand(s) this information.

If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician's approval to participate.

I also affirm that I alone am responsible to decide whether to practice yoga and participation of myself, and my minor child(-ren) if applicable, is at my own risk.

I knowingly, voluntarily and expressly waive any claim that I may have against BJ Hart, Courtney Hart, and any other instructors of Healing Hart Wellness, LLC/Polliwog Kids Yoga and any facility at which I, or my minor child(-ren) if applicable, attend a yoga session including its owners for any injury, death or damages that I may sustain as a result of participating in a yoga class, workshop, birthday party, or pre-registered yoga session, including loss that may be caused by the negligence of the released party.

I release and discharge BJ Hart, Courtney Hart and Healing Hart Wellness, LLC/Polliwog Kids Yoga from any and all liability, claim, demand or action that I may have related to loss, theft or damage of any of my, or my minor child(-ren)'s if applicable, personal property while at a facility.

I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. I am signing this agreement voluntarily and recognize that my signature serves as complete and unconditional release of all liability to the greatest extent allowed by law.

If signing for a minor child(-ren), I affirm that I am the parent or legal guardian for any minor child(-ren) listed above in this waiver. I understand that the entirety of this waiver also applies to my minor child(-ren) even where notation may have been left out in error.
Did you read and understand the waiver above? If your answer is "no" please stop and read the waiver before continuing. *
Do you have any questions about the waiver? If your answer is "Yes" do not continue. Stop and email us immediately at info@polliwogkidsyoga.com *
If you understand the waiver and do not have questions, Please write your name below to electronically sign the waiver above. *
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Please date your signature with today's date below. *
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