Greater Harmony Student Information Form

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Please fill out this form prior to taking your first class with Greater Harmony. If you questions, please email greaterharmony@gmail.com.

Email *

Name *

Address (street, city, state, zip) *

Date of Birth *

YYYY

Phone Number *

Email Address *

Health Concerns or Limitations *

Health Goals *

I hereby retain Barbara “Teddy” Piotrowski to provide me with instruction in various exercises, techniques and therapies (“Yoga Instruction”). I understand and acknowledge that Yoga Instruction includes physical activities, which could be difficult and may entail the risk of physical injury.I assume the responsibility to consult with a physician and/ or obtain advise as I consider reasonable and necessary, to determine that I am able to engage in these activities. I fully assume all risk of physical injury and release Barbara “Teddy” Piotrowski from any and all liability for injury, which I may suffer while engaging in Yoga Instruction. I also agree to defend, indemnify and hold Barbara “Teddy” Piotrowski harmless from any claims that may be asserted by myself or anyone as a result of any such injury. This release is binding upon me and all whose rights arise (directly or indirectly) from or through me.

I have read and agree to the terms above.

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