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Student Information Form

Contact Information
* designates required information
First Name:*
Middle Initial:
Last Name:*
Birthday:*	month/day (i.e., 04/08)
Email:*
Address Line 1:*
Address Line 2:
City:*
State:*
Zip Code:*
Home Phone:*
Business Phone:
Cell Phone:
Emergency Contact Information
Emergency Contact Name:*
Relationship:*
Emergency Contact Phone:*
Referred By:

	Website	We appreciate your participation in this part of the form. This will benefit our marketing and outreach directions. Thank you
	PhenomeNews Ad
	Other Newspaper Ad
	Friend/Family
Other:
	PT or Massage Clinic
	Another Student
Student Name:
Please read and approve the following terms and conditions statement before submitting form. Must be completed by participant (or parent or guardian if under 18 yeard old). I, , agree that yoga includes physical exertion, which may be strenuous at times. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present. I certify that I am physically fit and able to participate in the yoga practice. If I experience any pain or discomfort, I will listen to my body, adjust the posture and ask for guidance from the instructor. I understand that periodically during classes, I may receive hands-on adjustments from instructors to correct position and / or alignment. If I do not want physical adjustment, I will so inform the instructor at each class I attend. I understand that Yoga is not a substitute for medical attention, examination, diagnosis or treatment. I understand that is my responsibility to consult with a physician regarding my participation in Yoga classes. I affirm that I alone am responsible to decide whether to practice Yoga. I agree to assume all responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of my participation. I knowingly, voluntarily and expressly waive any claim I may have against evolve yoga studio & boutique, its officers, directors, employees and instructors for injury or damage that I may sustain as a result of my participation. I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to terms and conditions stated above. I agree that all information is correct, I have read terms and conditions and approve.
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