NEW STUDENT FORM Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth *Street Address *City, State & Zip *Phone # *Email *EMERGENCY CONTACT NAME *Emergency Contact RelationshipEmergency Contact Phone # *VOLUNTARY PARTICIPATION (Check the box to agree) *I have voluntarily chosen and request to participate in a yoga class, workshop, event or activity sponsored by The Yoga Center Retreat. I am voluntarily participating in these activities knowing that there is a risk of injury.ACKNOWLEDGEMENT (Check the box to agree) *I attest that I have a doctor's permission to exercise and that I am responsible for notifying my instructor of any illnesss, surgeries, injuries or conditions before each class I attend. I assume all responsibility and liability for any and all injuries I may sustain due to my participation in these activities.RELEASE (Check the box to agree) *I release The Yoga Center Retreat and its owners, employees and agents and will hold them harmless from any and all liability arising out of any personal injuries or damages, foreseeable or unforeseeable which may occur as a result of my participation in any class, program or activity sponsored by The Yoga Center Retreat. I declare myself physically and mentally sound and capable of participation in those classes, programs or activities.REFUNDS (Check the box to agree) *I understand that class fees are non-refundable and non-transferable unless otherwise stated.IMAGES & MEDIA (Select one) *YES, I AGREE to give The Yoga Center Retreat permission to use any images or video for use in advertising, promotions, marketing and packaging and that I have no right to additional compensation for use of any media.NO, I DO NOT AGREE to give The Yoga Center Retreat permission to use any images or video for use in advertising, promotions, marketing and packaging.How did you hear about us?ReferralSearch (e.g., Google)FacebookInstagramELECTRONIC SIGNATURE: By typing my name below, I acknowledge that I have read and agree to each of the terms. *Today's Date *Submit
