Student Waiver

Student Registration Form

Release Waiver - Please fill out completely before you participate in Christ-Focused Yoga.
Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Mobile Number *

Area Code Phone Number
Would you like to subscribe to our email list? *

Yes No
Would you like to receive our text message reminders? *

Yes No
Have you or anyone in your household been tested or had any COVID-19 related symptoms or fever in the last 21 days? *

Yes No
Have you traveled outside of your home state in the last 21 days? *

Yes No
To the best of your knowledge, have you been exposed to anyone who has tested positive for COVID-19? *

Yes No
Workout Disclaimer: I hereby consent I am voluntarily participating in Christ Focused Gentle Yoga / Restore Yin Yoga / Fit Flow Yoga in person and/or virtual yoga class and agree to assume all risks involved. I understand that Upstream Yoga and Kelly Newton does not provide medical insurance relative to accidents, injuries, communicable diseases, and/or death as a result of my voluntary participation in in-person and/or virtual yoga classes and I cannot hold Upstream Yoga or Kelly Newton or affiliated instructor(s) responsibly for any liability. I recognize that any form of physical activity that I voluntarily participate in could be a potential risk and that it involves a risk of possible injury, sickness or even death. I hereby affirm that I am voluntarily participating in these activities whether in person and/or virtual yoga classes with the knowledge of the risk involved. I agree to expressly assume and accept any and all risk of injury, sickness and/or death. I hereby affirm myself to be physically sound and suffering from no condition, aliment, impairment, disease, or other illness that would prevent my participation in in-person and/or virtual yoga classes. I declare that I have disclosed any and all medical history to Upstream Yoga, Kelly Newton and/or their affiliates to relevant to participate in in-person and/or virtual yoga classes. *

I agree
Do you have any physical or emotional concerns that could be aggravated by exercise (i.e. back, neck, shoulder or knee problems, arthritis, autoimmune disease, asthma, chronic disease/disability, PTSD, trauma). If yes, please explain: *
Photography & Video Disclaimer: I hereby authorize Upstream Yoga, Kelly Newton and KCN Photo to publish photographs and/or videos taken of me at Christ-Centered Yoga in-person and/or virtual yoga classes for use in printed, online, marketing, and video-based marketing materials, as well as any other publications. I release and hold harmless Upstream Yoga, Kelly Newton, and KCN Photo from any reasonable expectation of privacy or confidentiality associated with the images and/or videos specified above. I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with the taking or publication of these photographs/videos or participation in company marketing materials or other publications. I acknowledge and agree that publication of said photos and/or videos confers no rights of ownership or royalties whatsoever. I hereby release Upstream Yoga, Kelly Newton and KCN Photo, its contractors, its employees, and any third parties involved in the creation or publication of marketing materials, from liability for any claims by me or any third party in connection with my participation. *

I agree
Your privacy matters to me and your information is never shared.
Signature

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Student Registration Form