VYAYAM's Enrollment Form for In-Person / Online SARVANG Yog Classes
Please fill the form below.
Email address *
Your last name. *
Your answer
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 answer
Your first name. *
Your answer
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). *
Your answer
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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Participant's street address. *
Your answer
Participant's city. *
Your answer
Participant's state. *
Your answer
Participant's zip code. *
Your answer
Participant's phone number *
Your answer
Name of emergency contact *
Your answer
Relationship with emergency contact *
Your answer
Phone number of emergency contact *
Your answer
Primary physician's name *
Your answer
Primary physician's number *
Your answer
Please list any physical conditions or health problems that may limit your yoga practice in VYAYAM's In-person / Online SARVANG Yog classes : *
Your answer
What is your objective in joining VYAYAM's In-person / Online SARVANG Yog classes? *
Your answer
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 15 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 it 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.
Your answer
Waiver of Liability, Affirmation, and Signature
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 Yoga, Pilates, Aerobics,Strength-Training, Relaxation, Pranayam (Breathing Techniques) and Laughter. 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 and agree to abide by it. *
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Sign your full name below *
Your answer
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). *
Your answer
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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