Yoga Form - Nourish Mind + Body

Last Name
First Name
Address
Street Address City State / Province / Region ZIP / Postal Code
Birthdate
Age
Cell Phone
Home Phone
Work Phone
What Method Is Best To Reach You?
May we send you email notices regarding events, schedule changes, etc.?
Email
Emergency Contact
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Emergency Phone #
Have you practiced yoga/Pilate/Barre before? YES or NO
How Long?
What Style?
What Kind?
How did you hear about us?
WAIVER OF LIABILITY AND PROSPECTIVE RELEASE FORM
I, _________________________________________ hereby agree to the
following:
I am participating in physical activity at Nourish Mind + Body, LLC., with Audra
Bursae, which may include, but is not limited to Yoga and/or Pilates. I recognize that any physical activity may be strenuous and may cause injury, and I am fully aware of the risks and hazards involved in such activity.
I represent and warrant that I am physically fit and I and have no medical
condition that would prevent my full participation in these exercises. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in these classes or treatments. If I have any existing medical
condition, I have been cleared by my doctor to participate doing Pilates with Audra Bursae and will explain the details below.
____________________________________________________
Yes
Details
Type Name For Waiver
First Last
Participant Information
In consideration of being permitted to participate in these exercises, I expressly assume the risks involved, whether or not such risks were created or exacerbated by the Instructor. I release Audra Bursae and Nourish Mind + Body,
LLC, his/her heirs, executors, administrators and assigns, its officers, directors, shareholders, employees, teachers, lecturers, agents, health counselors and staff (collectively, the Releasees) from any and all liability, damages, causes of
action, allegations, suits, sums of money, claims and demands whatsoever, in
law, admiralty or equity, which against the Releasees, I ever had, now has or will have in the future against the Releasees, arising from my past or future participation with Pilates, unless arising from the gross negligence of the
Releasees.
Myself, my heirs or legal representatives , forever release from liability, waive, discharge and covenant not to Audra Bursae, nourish. mind and body wellness, the owners and its agents for any injury or death caused by any negligent act or omission.
I have read the above release form and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.
Yes
Signature of Participant
First Last
Date
*For students under 18 years old, please have a parent/guardian sign
PAYMENT & CANCELLATION POLICY *
Payment is by check or cash only. Checks should be made payable to CASH or Audra Bursae. Audra Bursae and Nourish Mind + Body, LLC. accept no responsibility for personal items lost or stolen on the premises.
- Yes
YOGA, BARRE, & PILATES SESSIONS:
Cancellations made with less than 15 hours notice are charged the full rate of the session. Cancellations should be made over the telephone, not by email. All pre-paid packages expire in 3 months from purchase date and there are no refunds for any reason once sessions have been purchased
- Yes
Client Signature
Date
Person Responsible for Payment of Account
First Last
Relationship
Address
Street Address City ZIP / Postal Code
Phone