Registration Form This information is collected solely for the safety of participants, and will never be shared or sold. Today's Date * MM DD YYYY Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Cell Phone * (###) ### #### Email * For cancellation of emergencies, how would you like to be contacted? * Emergency Contact Information * First Name Last Name Emergency Phone Number * Country (###) ### #### Relationship to Emergency Contact Hold Harmless Agreement and Disclosure Statement * I acknowledge that participation in yoga classes, yoga therapy, or strength training may involve, but is not limited to: physical activity with or without weights, meditative/mental practices and breath practices and agree that these activities, while beneficial, also include certain risks. I assert that I am physically and mentally able to participate in this program or I have spoken to my doctor about my health issues and, as such, am able to participate in yoga classes, yoga therapy or strength training. I do hereby release and forever discharge, for myself, my heirs, executors and administrators, any and all claims to collect damages which I may incur while participating in yoga therapy or any other program offered, and any and all rights to such damages against Angela Nicolosi dba The Art of WellBeing, her representatives, employees, agents or officials. By checking this box I agree to the above Hold Harmless Agreement and Disclosure Statement Thank you!
