SINGLE + MONTHLY PASSES Qigong Registration / Disclaimer

Full Name (first, mi, last)

Your Best Email address:

example@example.com

Contact Telephone:

Format: (000) 000-0000.

My Products

Single Session

Buy this single session if you just want to attend one class. Purchase it and then pick any Sunday to attend.

$17.00 Quantity

SENIOR/STUDENT Single Session

Seniors 65+ and enrolled college students, buy this single session if you just want to attend one class. Purchase it and then pick any Sunday to attend.

$15.00 Quantity

One Month Pass

Buy this one-month pass to attend for one calendar month, or for four consecutive Sundays starting from your purchase date.

$58.00 Quantity

SENIOR/STUDENT One Month Pass

Seniors 65+ and enrolled college students, buy this one-month pass to attend for one calendar month, or for four consecutive Sundays starting from your purchase date.

$58.00 Quantity

Total

Debit or Credit Card
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Expiration Month	Expiration Year

Address

Street Address

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Emergeny contact info (name and phone #)

Where did you hear about this Qigong class?

What are your main reasons for coming to Qigong class (check all that apply)

Other

Your main health concern or complaints (optional):

Please share anything you'd like Dr. Chen to know about your health situation.

Medical Disclaimer and Liability Waiver

I acknowledge and agree that the Qigong Classes, Bigu Retreats, Medical Qigong, Consultations and any other classes, workshops, retreats, tours, or recorded programs offered by Dr. Kevin W Chen and his associates (collectively referred to as “Programs”) are intended solely for educational and wellness purposes. These Programs are not medical treatment and do not provide medical advice, diagnosis, therapy, or prescription.

Consultation with Healthcare Provider
I understand and agree that it is my sole responsibility to consult with a licensed physician or other qualified healthcare practitioner regarding my current health status, medical conditions, or any concerns prior to participating in any of the Programs. I affirm that I will seek medical clearance if I have, or believe I may have, any physical or mental health concerns, or if I am pregnant, recovering from illness, injury, surgery, or taking medications. My participation signifies that I have either obtained such medical clearance or have voluntarily chosen to participate at my own risk.

Assumption of Risk and Release of Liability
I understand that participation in these Programs may include physical movement, breathing exercises, meditation, fasting, or dietary changes, all of which carry inherent risks, including but not limited to physical discomfort, dizziness, injury, or worsening of existing conditions. I voluntarily assume full responsibility for all risks, both known and unknown, associated with my participation.

In consideration of being permitted to participate, I knowingly, voluntarily, and expressly release, waive, discharge, and hold harmless Dr. Kevin Chen, his staff, associates, and any sponsoring or affiliated organizations from any and all liability, claims, demands, actions, or causes of action, including those arising from negligence, that may result from my participation in any of the Programs.

I further agree to indemnify and hold harmless Dr. Kevin W Chen, his staff, associates, and all affiliated entities from any and all claims, damages, losses, or expenses, including attorney’s fees, arising out of or related to my participation, to the fullest extent permitted by law.

This agreement shall be binding upon me, my heirs, executors, administrators, successors, and assigns. By signing below, I confirm that I have read, understood, and voluntarily agree to this Medical Disclaimer and Liability Waiver, and I acknowledge that I have been advised to seek medical consultation before participation.

Signature :

Date:

Date

SINGLE CLASS & MONTHLY PASS Qigong Class Registration

My Products