Student's Name #1 *

First Name

Last Name

Birthday #1 *

MM

DD

YYYY

Student's Name #2

Only if you have more than 1 child

First Name

Last Name

Birthday #2

MM

DD

YYYY

Caregiver's Name *

First Name

Last Name

Emergency Contact Number *

(###)

###

####

Name #1 *

First Name

Last Name

Phone Number #1 *

(###)

###

####

Name #2 *

First Name

Last Name

Phone Number #2 *

(###)

###

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Acknowledgement of Risk *

I hereby give the student permission to do yoga with The Yoga Buggy. I understand that yoga includes individual physical movements, supportive touch, group work as well as an opportunity for relaxation, stress reduction, and relief of muscular tension. I declare that the student is physically able and ready to participate in The Yoga buggy program. I understand that The Yoga Buggy will take all reasonable care to ensure that the classes are safe. However, as is the case with any physical activity, the risk of injury, even serious or disabling, is always present and can not entirely be eliminated. If the student experiences any pain or discomfort, the student will listen to his/her body, adjust the posture and ask for support from the teacher or practitioner. Yoga is not a substitute for medical attention, examination, diagnosis, or treatment. I affirm that I alone am responsible for deciding whether the student can practice yoga. I hereby agree to irrevocably release and waive The Yoga Buggy to any claims that I have now or hereafter may have against any and all The Yoga Buggy instructors. I have read and fully understand the above agreement terms and it is expressly agreed that Miriam Leo Gindin, The Yoga Buggy and its agents and independent contractors shall not be held liable for claim, demands, injuries, damages, actions or causes of action, whatsoever, to my child or property arising out of or connected with the yoga program or due to a pre-existing condition not disclosed by myself or other persons responsible for my child. By checking "YES" states my full acceptance and concurrence with the terms of this agreement.

Yes

Photo Release Form *

I grant to The Yoga Buggy, its representatives and employees the right to take photographs of the student in connection with the above-identified subject. I authorize The Yoga buggy, its assignees and transferees to copyright, use and publish the same in print and/or electronically. I agree that The Yoga buggy may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. I have read and understand the above.

Yes

No

Electronic Signature Consent *

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

Would you like to receive a reminder email one day before the first class of the program? *

Yes

No