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Register for 'Chakra Superpowers Yoga + Self-Esteem Summer Camp'
13
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1
Child Name
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Last Name
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2
Child's Birth Date
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Date
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Month
Day
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3
Parent Name / Legal Guardian Name
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4
Phone Number
Please enter a valid phone number.
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5
Email
Our primary method of communication is email -- by providing your email, you agree to be added to our Email list. You can unsubscribe at any time.
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6
Address
Why do we need this? Only for insurance and liability protection reasons - to verify identity, as well as emergency reasons. Your information is safe with us and we will not send any correspondence via mail unless it's a gift, or requested material for a specific program. If you have questions, leave this blank and send an email to ashley@ashleyanjlienkumar.net
Street Address
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US Virgin Islands
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Western Sahara
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Zambia
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Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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7
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ORDER SUMMARY
Total cost
CAD
July Summer Camp - Chakra Superpowers
All sales final.
$
299.00
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August Summer Camp - Chakra Superpowers
All sales final.
$
299.00
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8
Participants are required to bring a lunch, snack (optional), water bottle, their own yoga mat and sweater for cool-down/relaxation poses.
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9
Health & Well-being
Please advise of any allergies or medical conditions the child(ren) have; if required, we may request medical clearance for participation in the program if conducted live in our studio. Not applicable for online sessions.
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10
Liability Waiver and Release
Liability Wavier; please read carefully. Glossary: "Club/Studio" The Balance Code Yoga & Wellness Ltd. and The Confidence Coach, and Ashley Anjlien Kumar, and any associated partners/representatives involved in the class/event. Assumption of Risk of Injury and Wavier of Claims: I assume all risks of injury and waive all rights to pursue money damages or any other relief of any kind as a result of anything occurring at or near the Club/Studio location or any other venue used by the Club/Studio or its employees, officers, directors or other representatives (including but not limited to dance and/or fitness instructors and/or personal trainers and/or artists managed by the Club/Studio and/or contractors of any type). In the event I am injured while on a property the Club/Studio uses to conduct classes, performances, or workshops, I will hold harmless the Club/Studio and all of its owners, shareholders, directors, volunteers, sub-contractors, employees, agents, representatives, successors and assigns from all claims of any sort for damages or relief, including but not limited to claims for contribution. I acknowledge there is possible danger connected with any physical activity (including the dangers of physical injury and death) and knowingly and voluntarily waive my right to make a legal or equitable claim of any sort against the Club/Studio and all of its owners, shareholders, directors, volunteers, sub-contractors, employees, agents, representatives, successors and assigns from all claims of any sort for damages or for other relief, including but not limited to claims for contribution. This assumption of risk and wavier of liability applies to my family members, successors, heirs, and assigns. Physical Condition and No Medical Advice: I represent that I am in good physical condition and have no medical reason or impairment that might prevent me from my participation or intended use of the Club/Studio and the services offered. I acknowledge that the Club/Studio and all of its owners, shareholders, directors, volunteers, sub-contractors, employees, agents, representatives, successors and assigns will not and cannot provide me medical advice relating to my physical condition and ability to use the facilities/participate in programs/classes. If I have any health or medical concerns now or after joining a class, I will discuss them with my doctor before attending & participating in any classes or using the Club/Studio"s services. Death/Disability Clause: If I die or become totally or permanently disabled, upon reasonable written notice to the Studio/Club Owner of the death or disability, either I or my estate may cancel this agreement and receive a pro-rata refund for my unused sessions/classes. Cancellation and Refund: To cancel this agreement, the client must notify the Club/Studio Management in writing. FINAL SALE - NO REFUND; if for any reason the participant cannot complete the program, you may transfer the program to another suitable candidate who will benefit from the program. I, the undersigned, waive and release the Club/Studio and its owners, shareholders, directors, volunteers, sub-contractors, employees, agents, representatives, successors and assigns from any and all claims in any way connected with my participation. This agreement is binding on my heirs and executors. I understand that ALL aspects of this wavier apply to any children that I bring with me to any of the classes/programs/events/meetings or gatherings offered or facilitiated by Club/Studio. I acknowledge that I am the legal guardian of the child(ren) listed on this form (if any). By signing this document, I acknowledge that I have read or heard this document in its entirety and that I fully understand it. I have asked any questions that may have occurred to me and have been answered to my satisfaction. A legal guardian/parent must sign for any participants under the age of 18 years. Your typed signature below will be considered identical to your actual signature if this form is submitted electronically.
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11
Standard Photo & Video Release Form
I agree to grant to The Confidence Coach o/a The Balance Code Yoga & Wellness Ltd. and Adventures in Wisdom, Inc. and its authorized representatives permission to record on photography film and/or video, pictures of my participation and/or the undersigned minor children. I further agree that any or all of the material photographed may be used, in any form, as part of any future publications, brochure, or other printed or online materials used to promote The Confidence Coach and Adventures in Wisdom, and further that such use shall be without payment of fees, royalties, special credit or other compensation. I release The Confidence Coach (o/a The Balance Code Yoga & Wellness Ltd.) and Adventures in Wisdom, Inc. from any expectation of confidentiality for the undersigned minor children and myself and attest that I am the parent or legal guardian of the children listed below and that I have the authority to authorize The Confidence Coach (o/a The Balance Code Yoga & Wellness Ltd. and Adventures in Wisdom, Inc. to use their photographs, videos (names will not be shared)
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NO
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12
Would you be so kind as to tell us how you heard about this program?
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13
Payment Methods
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First Name
Last Name
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