Yoga Workshops Registration

SECURE SITE CONNECTION

Your information is private and secure when using this form.

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State

Zip Code

Phone Number *

Area Code Phone Number

Email *

example@example.com

Birthdate *

Date

Age

Sex *

Male Female

Do you have now, or have you had within the past year... *

YES

NO

History of Heart Problems?

High Blood Pressure?

Muscle, joint or back disorder that could
be aggravated by physical activity?

Surgery?

Diabetes?

High blood cholesterol?

Asthma?

Osteoporosis?

Do you smoke?

Are you presently taking any medications?

Are you now, or have you been pregnant
within the last three months?

Allergic/sensitive to fragrances?

If you answered YES to any of the above (except smoking), do you have your doctor's permission to exercise?

YES NO

You are registering for the following class: *

Shine Your Light 4-Week Yoga Workshops - $ 59.00

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Zip Code

THE MAKEUP POLICY:

Students are allowed 3 Makeup Classes per Workshop
1. In another current workshop during this time period
2. In a scheduled class this time period plus 2 weeks after

AGREEMENT:

I have truthfully and honestly disclosed all medial issues I have above. I waive any possibility of personal damage and waive any liability against Paula Bayer and Yoga Happens Here which may be blamed on such an exercise-yoga program and accept full responsibility for requesting such exercise and instruction. I voluntarily assume complete responsibility for my health and well-being in the voluntary yoga program or class and understand that no responsibility is assumed by Paula Bayer and Yoga Happens Here.

I am also ok with photos/video that may contain my image to be used in marketing material on websites and/or Facebook for promoting Yoga Happens Here.

*

By checking this box, I agree to the above statement.