Kids’ Yoga Registration Form

Student's Name *
Student's Name
Birthday *
Name of the school / centre
Caregiver's Name *
Caregiver's Name
Emergency Contact Phone Number *
Emergency Contact Phone Number
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.
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 selecting "YES" states my full acceptance and concurrence with the terms of this agreement.
Electronic Signature Consent* *

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