Mindful Movement & Medical Literacy Registration

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June 25, 2020; 2:00pm - 3:45pm

Participant name (first and last) *

Phone number

Email address *

Emergency Contact (Name and phone number)

Do you have any medical condition which may affect your learning and practicing tai chi or yoga? *

Yes

If you answered “yes” to the previous question, or if you are unsure you must have a doctor’s clearance before you take this class. Doctor's Clearance:

Yes

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I consent to the use of any photographs or videos taken of me, as well as my feedback or written comments by me in connection with the class for publicity, promotion, demonstration or other business purposes, in any medium, including the internet, and waive any right to compensation in connection with such use. *

Yes

I would like to receive limited communications from Healthy Acadia about their programming and services in our communities. *

Yes

By typing my name below, I acknowledge and understand that tai chi and yoga are gentle exercises, which may enhance my physical fitness. I confirm that my physical fitness is at a sufficient level to safely participate in this class. In consideration for admission to this class: (a) I hereby accept full responsibility for and assume the risk of any injuries sustained because of my participation in this class, practice, or lessons involving tai chi; and (b) I hereby release and hold harmless the instructor, Healthy Acadia and its partner sites, for any liabilities, injuries and expenses which may arise as a result of participation in this class or practice or lessons involving tai chi. I acknowledge that typing my name below equates to a physical signature. *

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