Tai Chi With Melissa Registration

Tai Chi With Melissa

Registration for In-Person classes at the Regent Health Centre, 150 Locke Street South, Hamilton, Ontario
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
HealthStress ReductionMeditationOther
Other, Please Specify
Any Concerns or Questions
YesNo
If yes, where and when?
Do you have any questions or concerns?
Please Note:

Melissa Smith and all co-instructors do not provide medical services and assume no responsibility for determining that you are medically fit and able to participate in classes, or to attend Regent Health and Chiropractic Centre, and their programs or activities. If in doubt, please consult a healthcare professional.

Tai Chi on Locke / Tai Chi With Melissa / Mountain View Tai Chi

Release, Waiver and Indemnity

In consideration of your acceptance of my application as a student of Regent Health and Chiropractic Centre and Melissa Smith, I, the undersigned, for myself, heirs, executors, administrator, assigns and personal representatives, hereby release, waive, and forever discharge you and your officers, directors, instructors, successors and assigns of and from all claims (including demands, damages, costs, expenses, actions and causes of action, whether in law or in equity) in respect of death, injury, loss, or damage to my person or property, howsoever caused, arising or to arise by reason of my participation in the activities and/or services offered by you in any manner whatsoever.

I further hereby undertake to hold and save harmless and agree to indemnify you and all of the aforesaid from and against any and all liability incurred by you and any or all of them as arising as a result of, or in any way connected with my participation in the activities and/or services offered by you in any manner whatsoever.

I agree to comply with the by-laws, rules, and code of conduct of Melissa Smith's classes, her co-instructors' classes, and Regent Health and Chiropractic Centre.
Date

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