Somatically Minded Holistic Wellness: Introduction to the Dart Procedures 10/18/20 Registration Form
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First Name *
Last Name *
Date of Birth *
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Gender Identity *
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Emergency Contact Name, Relationship, and Phone Number *
Are there any injuries or health concerns the teacher should be aware of? *
Mailing Address *
Phone Number *
Is okay to contact you about future classes and workshops offered by Somatically Minded Holistic Wellness? *
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What amount on the sliding scale of $5-$25 can you pay and what method will you be using? (Venmo is preferred @Sara-Yanney, PayPal sarayc.syc@gmail.com, cash will be accepted on the day of the event) If you are unable to pay anything right now, we still want you to come. *
Covid-19 Release: By attending this workshop, I agree to accept any risks of exposure to COVID-19. I will be truthful about my health and will not attend if I have had any symptoms of COVID-19 in the past 24 hours, have had direct contact with someone who has COVID-19, or have traveled out the area in the past two weeks. I will wear my mask at all times and maintain 6 feet distance from all other participants. Please initial below. *
Liability Release: By attending this workshop, I acknowledge that Somatically Minded Holistic Wellness is not responsible for any injuries or illness that may occur from my attendance of this workshop or from practicing anything from this workshop on my own in the future. Please initial below. *
Photo/Video Release: I agree to allow Somatically Minded Holistic Wellness to use my image in photo or video to be used for promotional purposes for future workshops and classes. I understand my name will not be used. *
I understand that taking this workshop does not qualify me to teach the Dart Procedures or the Alexander Technique. I understand that in order to teach the Alexander Technique as a certified AmSAT teacher, I must complete a 1600 hour training course. Please initial below. *
By typing my name below, I am acknowledging that I have read through this entire form and I understand all of the content. *
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