Yoga with Jem

Yoga with Jem

Registration and Waiver Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Emergency Contact*

NamePhone number
Please select dates attending

2/17/262/24/263/3/263/10/263/17/263/24/263/31/264/7/26
Are you currently experiencing any of the following?

AsthmaMuscular InjuryJoint InjuryPregnancyHigh blood pressureDizzy/Fainting spellsEpilepsySeizuresDiabetesSurgery in the last 6 monthsAnything else that needs to be shared with the instructor
Would you like the instructor to contact your regarding anything prior to the class?
I understand that participation in the Activity involves inherent risks, including risk of physical or psychological injury, and I assume all related risks and voluntarily participate in the Activity.

By signing below I release Mountainside Mobile Massage and my instructor from any liability of possible damages.
I agree to all of the above and that I have been open and honest about my health*

Agree
Signature*
Date*

MonthDayYear
Date
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