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Nourishing Breath Yoga, LLC Information Sheet and Waiver of Liability form for Online Yoga Classes and Video Recordings of Classes
The following named individual wishes to participate in Online Live Streaming Yoga Classes and/or Video Recordings of Yoga Classes provided by Marcie Leek and/or Nourishing Breath Yoga, LLC.
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Email
*
Your email
NAME (first and last name)
*
Your answer
Email Address
*
Your answer
ADDRESS (#, street, city, state, zip, country)
*
Your answer
Date of Birth (IF YOU ARE UNDER THE AGE OF 18, THIS AGREEMENT MUST BE COMPLETED BY YOUR PARENT OR LEGAL GUARDIAN. PLEASE CONTACT
marcie@nourishingbreathyoga.com
FOR THE APPROPRIATE FORM).
*
MM
/
DD
/
YYYY
Phone number:
*
Your answer
Person to contact in case of Emergency:
*
Your answer
Which class/series are you registering for?
*
Befriending Your Body through Yoga, Level 1
Befriending Your Body through Yoga, Level 2
Moving through Grief with Yoga
Yoga for Knotted Knitters
Stress Rx Yoga
Befriending Your Body through Yoga: Healthier, Happier Hips
Thursday Evening Stretch
See You Saturday!
Other:
Required
Check any area where you have pain, problems, or limitations:
neck
upper back
shoulders
mid-back
low back
knees
ankles/feet
hips
Other:
Please list all other physical conditions, limitations, concerns, or injuries
Your answer
Are you physically pregnant, or have you had a child within the past three months?
Yes
No
Clear selection
How did you learn about this class?
Your answer
Would you like to be added to the Nourishing Breath Yoga mailing list to receive notice about upcoming classes?
Yes
No
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