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Mystic Yoga Shala

80 Stonington Road

Mystic CT 06355

 

AGREEMENT OF RELEASE AND WAIVER OF LIABILITY

I hereby agree to the following:

1. That I am participating in the Yoga Classes, Dance Classes, Health Programs or Workshops, offered by the Mystic Yoga Shala during which I will receive information and instruction about yoga and health. I recognize that yoga and the other forms of fitness taught at the Mystic Yoga Shala require physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.

2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Yoga Classes, Dance Classes, Health Programs or Workshops. I represent and warrant that I am physically fit and I have no medical condition which would prevent my full participation in the Yoga Classes, Dance Classes, Health Programs or Workshops.

3. In consideration of being permitted to participate in the Yoga Classes, Dance Classes, Health Programs or Workshops, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the programs.

4. In further consideration of being permitted to participate in the Yoga Classes, Dance Classes, Health Programs or Workshops, I knowingly, voluntarily and expressly waive any claim I may have against the Mystic Yoga Shala, its instructors and staff, its owners, and class/workshop Sponsors for any injury or damages that I may sustain as a result of participating in the program.

5. I, my heirs or legal representatives, forever release, waive, discharge and covenant not to sue the Mystic Yoga Shala, its instructors, staff, its owners, or class/workshop Sponsors for any injury or death caused by their negligence or other acts.

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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