Please refer to our current privacy policy on our website.

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YOGICUBS / TODDLER & CAREGIVER YOGA REGISTRATION FORM


Review Anicca Yoga Privacy Policy

The information contained in this form is strictly confidential and will not be disclosed to any third party without your consent. The information in this form is used to ensure we can teach you (and/or your child) safely and respectfully. 

Today's Date: December 10, 2019

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
Has your Primary Care Provider informed you of any restrictions, contraindications or other concerns that may prevent or inhibit you/your child from practicing yoga?*
Yes
No
Are you/your child currently experiencing any pain, illness and/or other receiving medical treatment of any kind?*
Yes
No

If yes, please detail.
Do you/your child currently have any of the following conditions? ​ (tick all that apply)
Arthritis
Asthma
Autism
Carpal Tunnel Syndrome and/or wrist pain
Depression and/or Anxiety
Developmental Delay or Disorder (child only)
Diabetes
Dizziness and/or Fainting
Epilepsy
Eye condition and/or Sight Impairment
Hearing Issue
Heart Condition
High Blood Pressure
Learning Disorder
Low Blood Pressure
Lower Back Pain
Neck Pain
Pelvic Pain and/or Sciatica
Shoulder Pain
Any other medical condition or disability we should be aware of?
Photography Permission & Release I give permission to be photographed, or have my image recorded for digital use including on social media. I understand this may be used to promote the services and classes I am participating in, even if I am no longer participating. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses of new photographs. I agree that this form will remain in effect during the term of my participation. I understand that there will be no payment for my participation.*

1. I have read and fully understand the contents of this form and confirm that my answers are true to the best of my knowledge.
2. I confirm that my participation in the classes taught at and by Anicca Yoga and it's instructors is voluntary.
3. I understand that any advice provided to me by any director, employee or instructor at 4. Anicca Yoga is followed at my own risk.
I willingly declare, understand and accept the following:
4.1.  I have no medical conditions which would prevent me from participating in the classes I will attend or have attended. 
4.2.  I have declared within the past 3 months (or since my most recent birth and/or medical treatment) by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga.
4.3.  If attending with a minor, the minor has been recently declared by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga. 
4.4.  If at any time this changes I will inform you in writing prior to taking any more classes.
5. I, my heirs and legal representatives knowingly and voluntarily waive any future claim I may have against Anicca Yoga or any Director, employee or instructor at Anicca Yoga for any injury, condition, or damages I may sustain from being on your premises, participating in classes or following advice.
6. Any fees or membership dues paid by me are not refundable other than at the sole discretion of Anicca Yoga and as stipulated in the terms and conditions I was provided at the time of booking. In the instance bookings have been made through a third partner I understand that the third party's cancellation and refund policy applies and accept that Anicca Yoga is not responsible for any cancellation or refund. 
7. Anicca Yoga and its employees, contractors and volunteers reserves the right to refuse access and may terminate my membership at any time for any reason. In such event, my compensation is limited to the unused amount if any dues paid.
8. Anicca Yoga is not liable for any loss, theft or damage occurring to any personal property on any premises in which classes are taught including Anicca Yoga studio, third party studios or locations and/or clients home or other location. 
9. We may use some of the information you have provided for the purpose of monitoring, assessing or marketing Anicca Yoga and to inform you of offers, information and other services and products on occasions. 
10. We undertake not to sell or otherwise distribute any personal information of you to third parties.
11. I understand that this contract is subject to California State Law and where applicable the federal Law of the United States of America and United States Court jurisdiction.

12. I have read the above agreement and the waiver and release of liability and fully understand its contents. I voluntarily agree to Anicca Yoga Terms and Conditions. 

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Has your Primary Care Provider informed you of any restrictions, contraindications or other concerns that may prevent or inhibit you/your child from practicing yoga?*
Yes
No
Are you/your child currently experiencing any pain, illness and/or other receiving medical treatment of any kind?*
Yes
No

If yes, please detail.
Do you/your child currently have any of the following conditions? ​ (tick all that apply)
Arthritis
Asthma
Autism
Carpal Tunnel Syndrome and/or wrist pain
Depression and/or Anxiety
Developmental Delay or Disorder (child only)
Diabetes
Dizziness and/or Fainting
Epilepsy
Eye condition and/or Sight Impairment
Hearing Issue
Heart Condition
High Blood Pressure
Learning Disorder
Low Blood Pressure
Lower Back Pain
Neck Pain
Pelvic Pain and/or Sciatica
Shoulder Pain
Any other medical condition or disability we should be aware of?
Photography Permission & Release I give permission to be photographed, or have my image recorded for digital use including on social media. I understand this may be used to promote the services and classes I am participating in, even if I am no longer participating. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses of new photographs. I agree that this form will remain in effect during the term of my participation. I understand that there will be no payment for my participation.*

1. I have read and fully understand the contents of this form and confirm that my answers are true to the best of my knowledge.
2. I confirm that my participation in the classes taught at and by Anicca Yoga and it's instructors is voluntary.
3. I understand that any advice provided to me by any director, employee or instructor at 4. Anicca Yoga is followed at my own risk.
I willingly declare, understand and accept the following:
4.1.  I have no medical conditions which would prevent me from participating in the classes I will attend or have attended. 
4.2.  I have declared within the past 3 months (or since my most recent birth and/or medical treatment) by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga.
4.3.  If attending with a minor, the minor has been recently declared by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga. 
4.4.  If at any time this changes I will inform you in writing prior to taking any more classes.
5. I, my heirs and legal representatives knowingly and voluntarily waive any future claim I may have against Anicca Yoga or any Director, employee or instructor at Anicca Yoga for any injury, condition, or damages I may sustain from being on your premises, participating in classes or following advice.
6. Any fees or membership dues paid by me are not refundable other than at the sole discretion of Anicca Yoga and as stipulated in the terms and conditions I was provided at the time of booking. In the instance bookings have been made through a third partner I understand that the third party's cancellation and refund policy applies and accept that Anicca Yoga is not responsible for any cancellation or refund. 
7. Anicca Yoga and its employees, contractors and volunteers reserves the right to refuse access and may terminate my membership at any time for any reason. In such event, my compensation is limited to the unused amount if any dues paid.
8. Anicca Yoga is not liable for any loss, theft or damage occurring to any personal property on any premises in which classes are taught including Anicca Yoga studio, third party studios or locations and/or clients home or other location. 
9. We may use some of the information you have provided for the purpose of monitoring, assessing or marketing Anicca Yoga and to inform you of offers, information and other services and products on occasions. 
10. We undertake not to sell or otherwise distribute any personal information of you to third parties.
11. I understand that this contract is subject to California State Law and where applicable the federal Law of the United States of America and United States Court jurisdiction.

12. I have read the above agreement and the waiver and release of liability and fully understand its contents. I voluntarily agree to Anicca Yoga Terms and Conditions. 

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Has your Primary Care Provider informed you of any restrictions, contraindications or other concerns that may prevent or inhibit you/your child from practicing yoga?*
Yes
No
Are you/your child currently experiencing any pain, illness and/or other receiving medical treatment of any kind?*
Yes
No

If yes, please detail.
Do you/your child currently have any of the following conditions? ​ (tick all that apply)
Arthritis
Asthma
Autism
Carpal Tunnel Syndrome and/or wrist pain
Depression and/or Anxiety
Developmental Delay or Disorder (child only)
Diabetes
Dizziness and/or Fainting
Epilepsy
Eye condition and/or Sight Impairment
Hearing Issue
Heart Condition
High Blood Pressure
Learning Disorder
Low Blood Pressure
Lower Back Pain
Neck Pain
Pelvic Pain and/or Sciatica
Shoulder Pain
Any other medical condition or disability we should be aware of?
Photography Permission & Release I give permission to be photographed, or have my image recorded for digital use including on social media. I understand this may be used to promote the services and classes I am participating in, even if I am no longer participating. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses of new photographs. I agree that this form will remain in effect during the term of my participation. I understand that there will be no payment for my participation.*

1. I have read and fully understand the contents of this form and confirm that my answers are true to the best of my knowledge.
2. I confirm that my participation in the classes taught at and by Anicca Yoga and it's instructors is voluntary.
3. I understand that any advice provided to me by any director, employee or instructor at 4. Anicca Yoga is followed at my own risk.
I willingly declare, understand and accept the following:
4.1.  I have no medical conditions which would prevent me from participating in the classes I will attend or have attended. 
4.2.  I have declared within the past 3 months (or since my most recent birth and/or medical treatment) by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga.
4.3.  If attending with a minor, the minor has been recently declared by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga. 
4.4.  If at any time this changes I will inform you in writing prior to taking any more classes.
5. I, my heirs and legal representatives knowingly and voluntarily waive any future claim I may have against Anicca Yoga or any Director, employee or instructor at Anicca Yoga for any injury, condition, or damages I may sustain from being on your premises, participating in classes or following advice.
6. Any fees or membership dues paid by me are not refundable other than at the sole discretion of Anicca Yoga and as stipulated in the terms and conditions I was provided at the time of booking. In the instance bookings have been made through a third partner I understand that the third party's cancellation and refund policy applies and accept that Anicca Yoga is not responsible for any cancellation or refund. 
7. Anicca Yoga and its employees, contractors and volunteers reserves the right to refuse access and may terminate my membership at any time for any reason. In such event, my compensation is limited to the unused amount if any dues paid.
8. Anicca Yoga is not liable for any loss, theft or damage occurring to any personal property on any premises in which classes are taught including Anicca Yoga studio, third party studios or locations and/or clients home or other location. 
9. We may use some of the information you have provided for the purpose of monitoring, assessing or marketing Anicca Yoga and to inform you of offers, information and other services and products on occasions. 
10. We undertake not to sell or otherwise distribute any personal information of you to third parties.
11. I understand that this contract is subject to California State Law and where applicable the federal Law of the United States of America and United States Court jurisdiction.

12. I have read the above agreement and the waiver and release of liability and fully understand its contents. I voluntarily agree to Anicca Yoga Terms and Conditions. 

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Has your Primary Care Provider informed you of any restrictions, contraindications or other concerns that may prevent or inhibit you/your child from practicing yoga?*
Yes
No
Are you/your child currently experiencing any pain, illness and/or other receiving medical treatment of any kind?*
Yes
No

If yes, please detail.
Do you/your child currently have any of the following conditions? ​ (tick all that apply)
Arthritis
Asthma
Autism
Carpal Tunnel Syndrome and/or wrist pain
Depression and/or Anxiety
Developmental Delay or Disorder (child only)
Diabetes
Dizziness and/or Fainting
Epilepsy
Eye condition and/or Sight Impairment
Hearing Issue
Heart Condition
High Blood Pressure
Learning Disorder
Low Blood Pressure
Lower Back Pain
Neck Pain
Pelvic Pain and/or Sciatica
Shoulder Pain
Any other medical condition or disability we should be aware of?
Photography Permission & Release I give permission to be photographed, or have my image recorded for digital use including on social media. I understand this may be used to promote the services and classes I am participating in, even if I am no longer participating. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses of new photographs. I agree that this form will remain in effect during the term of my participation. I understand that there will be no payment for my participation.*

1. I have read and fully understand the contents of this form and confirm that my answers are true to the best of my knowledge.
2. I confirm that my participation in the classes taught at and by Anicca Yoga and it's instructors is voluntary.
3. I understand that any advice provided to me by any director, employee or instructor at 4. Anicca Yoga is followed at my own risk.
I willingly declare, understand and accept the following:
4.1.  I have no medical conditions which would prevent me from participating in the classes I will attend or have attended. 
4.2.  I have declared within the past 3 months (or since my most recent birth and/or medical treatment) by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga.
4.3.  If attending with a minor, the minor has been recently declared by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga. 
4.4.  If at any time this changes I will inform you in writing prior to taking any more classes.
5. I, my heirs and legal representatives knowingly and voluntarily waive any future claim I may have against Anicca Yoga or any Director, employee or instructor at Anicca Yoga for any injury, condition, or damages I may sustain from being on your premises, participating in classes or following advice.
6. Any fees or membership dues paid by me are not refundable other than at the sole discretion of Anicca Yoga and as stipulated in the terms and conditions I was provided at the time of booking. In the instance bookings have been made through a third partner I understand that the third party's cancellation and refund policy applies and accept that Anicca Yoga is not responsible for any cancellation or refund. 
7. Anicca Yoga and its employees, contractors and volunteers reserves the right to refuse access and may terminate my membership at any time for any reason. In such event, my compensation is limited to the unused amount if any dues paid.
8. Anicca Yoga is not liable for any loss, theft or damage occurring to any personal property on any premises in which classes are taught including Anicca Yoga studio, third party studios or locations and/or clients home or other location. 
9. We may use some of the information you have provided for the purpose of monitoring, assessing or marketing Anicca Yoga and to inform you of offers, information and other services and products on occasions. 
10. We undertake not to sell or otherwise distribute any personal information of you to third parties.
11. I understand that this contract is subject to California State Law and where applicable the federal Law of the United States of America and United States Court jurisdiction.

12. I have read the above agreement and the waiver and release of liability and fully understand its contents. I voluntarily agree to Anicca Yoga Terms and Conditions. 

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Has your Primary Care Provider informed you of any restrictions, contraindications or other concerns that may prevent or inhibit you/your child from practicing yoga?*
Yes
No
Are you/your child currently experiencing any pain, illness and/or other receiving medical treatment of any kind?*
Yes
No

If yes, please detail.
Do you/your child currently have any of the following conditions? ​ (tick all that apply)
Arthritis
Asthma
Autism
Carpal Tunnel Syndrome and/or wrist pain
Depression and/or Anxiety
Developmental Delay or Disorder (child only)
Diabetes
Dizziness and/or Fainting
Epilepsy
Eye condition and/or Sight Impairment
Hearing Issue
Heart Condition
High Blood Pressure
Learning Disorder
Low Blood Pressure
Lower Back Pain
Neck Pain
Pelvic Pain and/or Sciatica
Shoulder Pain
Any other medical condition or disability we should be aware of?
Photography Permission & Release I give permission to be photographed, or have my image recorded for digital use including on social media. I understand this may be used to promote the services and classes I am participating in, even if I am no longer participating. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses of new photographs. I agree that this form will remain in effect during the term of my participation. I understand that there will be no payment for my participation.*

1. I have read and fully understand the contents of this form and confirm that my answers are true to the best of my knowledge.
2. I confirm that my participation in the classes taught at and by Anicca Yoga and it's instructors is voluntary.
3. I understand that any advice provided to me by any director, employee or instructor at 4. Anicca Yoga is followed at my own risk.
I willingly declare, understand and accept the following:
4.1.  I have no medical conditions which would prevent me from participating in the classes I will attend or have attended. 
4.2.  I have declared within the past 3 months (or since my most recent birth and/or medical treatment) by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga.
4.3.  If attending with a minor, the minor has been recently declared by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga. 
4.4.  If at any time this changes I will inform you in writing prior to taking any more classes.
5. I, my heirs and legal representatives knowingly and voluntarily waive any future claim I may have against Anicca Yoga or any Director, employee or instructor at Anicca Yoga for any injury, condition, or damages I may sustain from being on your premises, participating in classes or following advice.
6. Any fees or membership dues paid by me are not refundable other than at the sole discretion of Anicca Yoga and as stipulated in the terms and conditions I was provided at the time of booking. In the instance bookings have been made through a third partner I understand that the third party's cancellation and refund policy applies and accept that Anicca Yoga is not responsible for any cancellation or refund. 
7. Anicca Yoga and its employees, contractors and volunteers reserves the right to refuse access and may terminate my membership at any time for any reason. In such event, my compensation is limited to the unused amount if any dues paid.
8. Anicca Yoga is not liable for any loss, theft or damage occurring to any personal property on any premises in which classes are taught including Anicca Yoga studio, third party studios or locations and/or clients home or other location. 
9. We may use some of the information you have provided for the purpose of monitoring, assessing or marketing Anicca Yoga and to inform you of offers, information and other services and products on occasions. 
10. We undertake not to sell or otherwise distribute any personal information of you to third parties.
11. I understand that this contract is subject to California State Law and where applicable the federal Law of the United States of America and United States Court jurisdiction.

12. I have read the above agreement and the waiver and release of liability and fully understand its contents. I voluntarily agree to Anicca Yoga Terms and Conditions. 

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Has your Primary Care Provider informed you of any restrictions, contraindications or other concerns that may prevent or inhibit you/your child from practicing yoga?*
Yes
No
Are you/your child currently experiencing any pain, illness and/or other receiving medical treatment of any kind?*
Yes
No

If yes, please detail.
Do you/your child currently have any of the following conditions? ​ (tick all that apply)
Arthritis
Asthma
Autism
Carpal Tunnel Syndrome and/or wrist pain
Depression and/or Anxiety
Developmental Delay or Disorder (child only)
Diabetes
Dizziness and/or Fainting
Epilepsy
Eye condition and/or Sight Impairment
Hearing Issue
Heart Condition
High Blood Pressure
Learning Disorder
Low Blood Pressure
Lower Back Pain
Neck Pain
Pelvic Pain and/or Sciatica
Shoulder Pain
Any other medical condition or disability we should be aware of?
Photography Permission & Release I give permission to be photographed, or have my image recorded for digital use including on social media. I understand this may be used to promote the services and classes I am participating in, even if I am no longer participating. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses of new photographs. I agree that this form will remain in effect during the term of my participation. I understand that there will be no payment for my participation.*

1. I have read and fully understand the contents of this form and confirm that my answers are true to the best of my knowledge.
2. I confirm that my participation in the classes taught at and by Anicca Yoga and it's instructors is voluntary.
3. I understand that any advice provided to me by any director, employee or instructor at 4. Anicca Yoga is followed at my own risk.
I willingly declare, understand and accept the following:
4.1.  I have no medical conditions which would prevent me from participating in the classes I will attend or have attended. 
4.2.  I have declared within the past 3 months (or since my most recent birth and/or medical treatment) by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga.
4.3.  If attending with a minor, the minor has been recently declared by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga. 
4.4.  If at any time this changes I will inform you in writing prior to taking any more classes.
5. I, my heirs and legal representatives knowingly and voluntarily waive any future claim I may have against Anicca Yoga or any Director, employee or instructor at Anicca Yoga for any injury, condition, or damages I may sustain from being on your premises, participating in classes or following advice.
6. Any fees or membership dues paid by me are not refundable other than at the sole discretion of Anicca Yoga and as stipulated in the terms and conditions I was provided at the time of booking. In the instance bookings have been made through a third partner I understand that the third party's cancellation and refund policy applies and accept that Anicca Yoga is not responsible for any cancellation or refund. 
7. Anicca Yoga and its employees, contractors and volunteers reserves the right to refuse access and may terminate my membership at any time for any reason. In such event, my compensation is limited to the unused amount if any dues paid.
8. Anicca Yoga is not liable for any loss, theft or damage occurring to any personal property on any premises in which classes are taught including Anicca Yoga studio, third party studios or locations and/or clients home or other location. 
9. We may use some of the information you have provided for the purpose of monitoring, assessing or marketing Anicca Yoga and to inform you of offers, information and other services and products on occasions. 
10. We undertake not to sell or otherwise distribute any personal information of you to third parties.
11. I understand that this contract is subject to California State Law and where applicable the federal Law of the United States of America and United States Court jurisdiction.

12. I have read the above agreement and the waiver and release of liability and fully understand its contents. I voluntarily agree to Anicca Yoga Terms and Conditions. 

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Has your Primary Care Provider informed you of any restrictions, contraindications or other concerns that may prevent or inhibit you/your child from practicing yoga?*
Yes
No
Are you/your child currently experiencing any pain, illness and/or other receiving medical treatment of any kind?*
Yes
No

If yes, please detail.
Do you/your child currently have any of the following conditions? ​ (tick all that apply)
Arthritis
Asthma
Autism
Carpal Tunnel Syndrome and/or wrist pain
Depression and/or Anxiety
Developmental Delay or Disorder (child only)
Diabetes
Dizziness and/or Fainting
Epilepsy
Eye condition and/or Sight Impairment
Hearing Issue
Heart Condition
High Blood Pressure
Learning Disorder
Low Blood Pressure
Lower Back Pain
Neck Pain
Pelvic Pain and/or Sciatica
Shoulder Pain
Any other medical condition or disability we should be aware of?
Photography Permission & Release I give permission to be photographed, or have my image recorded for digital use including on social media. I understand this may be used to promote the services and classes I am participating in, even if I am no longer participating. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses of new photographs. I agree that this form will remain in effect during the term of my participation. I understand that there will be no payment for my participation.*

1. I have read and fully understand the contents of this form and confirm that my answers are true to the best of my knowledge.
2. I confirm that my participation in the classes taught at and by Anicca Yoga and it's instructors is voluntary.
3. I understand that any advice provided to me by any director, employee or instructor at 4. Anicca Yoga is followed at my own risk.
I willingly declare, understand and accept the following:
4.1.  I have no medical conditions which would prevent me from participating in the classes I will attend or have attended. 
4.2.  I have declared within the past 3 months (or since my most recent birth and/or medical treatment) by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga.
4.3.  If attending with a minor, the minor has been recently declared by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga. 
4.4.  If at any time this changes I will inform you in writing prior to taking any more classes.
5. I, my heirs and legal representatives knowingly and voluntarily waive any future claim I may have against Anicca Yoga or any Director, employee or instructor at Anicca Yoga for any injury, condition, or damages I may sustain from being on your premises, participating in classes or following advice.
6. Any fees or membership dues paid by me are not refundable other than at the sole discretion of Anicca Yoga and as stipulated in the terms and conditions I was provided at the time of booking. In the instance bookings have been made through a third partner I understand that the third party's cancellation and refund policy applies and accept that Anicca Yoga is not responsible for any cancellation or refund. 
7. Anicca Yoga and its employees, contractors and volunteers reserves the right to refuse access and may terminate my membership at any time for any reason. In such event, my compensation is limited to the unused amount if any dues paid.
8. Anicca Yoga is not liable for any loss, theft or damage occurring to any personal property on any premises in which classes are taught including Anicca Yoga studio, third party studios or locations and/or clients home or other location. 
9. We may use some of the information you have provided for the purpose of monitoring, assessing or marketing Anicca Yoga and to inform you of offers, information and other services and products on occasions. 
10. We undertake not to sell or otherwise distribute any personal information of you to third parties.
11. I understand that this contract is subject to California State Law and where applicable the federal Law of the United States of America and United States Court jurisdiction.

12. I have read the above agreement and the waiver and release of liability and fully understand its contents. I voluntarily agree to Anicca Yoga Terms and Conditions. 

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Has your Primary Care Provider informed you of any restrictions, contraindications or other concerns that may prevent or inhibit you/your child from practicing yoga?*
Yes
No
Are you/your child currently experiencing any pain, illness and/or other receiving medical treatment of any kind?*
Yes
No

If yes, please detail.
Do you/your child currently have any of the following conditions? ​ (tick all that apply)
Arthritis
Asthma
Autism
Carpal Tunnel Syndrome and/or wrist pain
Depression and/or Anxiety
Developmental Delay or Disorder (child only)
Diabetes
Dizziness and/or Fainting
Epilepsy
Eye condition and/or Sight Impairment
Hearing Issue
Heart Condition
High Blood Pressure
Learning Disorder
Low Blood Pressure
Lower Back Pain
Neck Pain
Pelvic Pain and/or Sciatica
Shoulder Pain
Any other medical condition or disability we should be aware of?
Photography Permission & Release I give permission to be photographed, or have my image recorded for digital use including on social media. I understand this may be used to promote the services and classes I am participating in, even if I am no longer participating. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses of new photographs. I agree that this form will remain in effect during the term of my participation. I understand that there will be no payment for my participation.*

1. I have read and fully understand the contents of this form and confirm that my answers are true to the best of my knowledge.
2. I confirm that my participation in the classes taught at and by Anicca Yoga and it's instructors is voluntary.
3. I understand that any advice provided to me by any director, employee or instructor at 4. Anicca Yoga is followed at my own risk.
I willingly declare, understand and accept the following:
4.1.  I have no medical conditions which would prevent me from participating in the classes I will attend or have attended. 
4.2.  I have declared within the past 3 months (or since my most recent birth and/or medical treatment) by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga.
4.3.  If attending with a minor, the minor has been recently declared by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga. 
4.4.  If at any time this changes I will inform you in writing prior to taking any more classes.
5. I, my heirs and legal representatives knowingly and voluntarily waive any future claim I may have against Anicca Yoga or any Director, employee or instructor at Anicca Yoga for any injury, condition, or damages I may sustain from being on your premises, participating in classes or following advice.
6. Any fees or membership dues paid by me are not refundable other than at the sole discretion of Anicca Yoga and as stipulated in the terms and conditions I was provided at the time of booking. In the instance bookings have been made through a third partner I understand that the third party's cancellation and refund policy applies and accept that Anicca Yoga is not responsible for any cancellation or refund. 
7. Anicca Yoga and its employees, contractors and volunteers reserves the right to refuse access and may terminate my membership at any time for any reason. In such event, my compensation is limited to the unused amount if any dues paid.
8. Anicca Yoga is not liable for any loss, theft or damage occurring to any personal property on any premises in which classes are taught including Anicca Yoga studio, third party studios or locations and/or clients home or other location. 
9. We may use some of the information you have provided for the purpose of monitoring, assessing or marketing Anicca Yoga and to inform you of offers, information and other services and products on occasions. 
10. We undertake not to sell or otherwise distribute any personal information of you to third parties.
11. I understand that this contract is subject to California State Law and where applicable the federal Law of the United States of America and United States Court jurisdiction.

12. I have read the above agreement and the waiver and release of liability and fully understand its contents. I voluntarily agree to Anicca Yoga Terms and Conditions. 

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Has your Primary Care Provider informed you of any restrictions, contraindications or other concerns that may prevent or inhibit you/your child from practicing yoga?*
Yes
No
Are you/your child currently experiencing any pain, illness and/or other receiving medical treatment of any kind?*
Yes
No

If yes, please detail.
Do you/your child currently have any of the following conditions? ​ (tick all that apply)
Arthritis
Asthma
Autism
Carpal Tunnel Syndrome and/or wrist pain
Depression and/or Anxiety
Developmental Delay or Disorder (child only)
Diabetes
Dizziness and/or Fainting
Epilepsy
Eye condition and/or Sight Impairment
Hearing Issue
Heart Condition
High Blood Pressure
Learning Disorder
Low Blood Pressure
Lower Back Pain
Neck Pain
Pelvic Pain and/or Sciatica
Shoulder Pain
Any other medical condition or disability we should be aware of?
Photography Permission & Release I give permission to be photographed, or have my image recorded for digital use including on social media. I understand this may be used to promote the services and classes I am participating in, even if I am no longer participating. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses of new photographs. I agree that this form will remain in effect during the term of my participation. I understand that there will be no payment for my participation.*

1. I have read and fully understand the contents of this form and confirm that my answers are true to the best of my knowledge.
2. I confirm that my participation in the classes taught at and by Anicca Yoga and it's instructors is voluntary.
3. I understand that any advice provided to me by any director, employee or instructor at 4. Anicca Yoga is followed at my own risk.
I willingly declare, understand and accept the following:
4.1.  I have no medical conditions which would prevent me from participating in the classes I will attend or have attended. 
4.2.  I have declared within the past 3 months (or since my most recent birth and/or medical treatment) by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga.
4.3.  If attending with a minor, the minor has been recently declared by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga. 
4.4.  If at any time this changes I will inform you in writing prior to taking any more classes.
5. I, my heirs and legal representatives knowingly and voluntarily waive any future claim I may have against Anicca Yoga or any Director, employee or instructor at Anicca Yoga for any injury, condition, or damages I may sustain from being on your premises, participating in classes or following advice.
6. Any fees or membership dues paid by me are not refundable other than at the sole discretion of Anicca Yoga and as stipulated in the terms and conditions I was provided at the time of booking. In the instance bookings have been made through a third partner I understand that the third party's cancellation and refund policy applies and accept that Anicca Yoga is not responsible for any cancellation or refund. 
7. Anicca Yoga and its employees, contractors and volunteers reserves the right to refuse access and may terminate my membership at any time for any reason. In such event, my compensation is limited to the unused amount if any dues paid.
8. Anicca Yoga is not liable for any loss, theft or damage occurring to any personal property on any premises in which classes are taught including Anicca Yoga studio, third party studios or locations and/or clients home or other location. 
9. We may use some of the information you have provided for the purpose of monitoring, assessing or marketing Anicca Yoga and to inform you of offers, information and other services and products on occasions. 
10. We undertake not to sell or otherwise distribute any personal information of you to third parties.
11. I understand that this contract is subject to California State Law and where applicable the federal Law of the United States of America and United States Court jurisdiction.

12. I have read the above agreement and the waiver and release of liability and fully understand its contents. I voluntarily agree to Anicca Yoga Terms and Conditions. 

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Has your Primary Care Provider informed you of any restrictions, contraindications or other concerns that may prevent or inhibit you/your child from practicing yoga?*
Yes
No
Are you/your child currently experiencing any pain, illness and/or other receiving medical treatment of any kind?*
Yes
No

If yes, please detail.
Do you/your child currently have any of the following conditions? ​ (tick all that apply)
Arthritis
Asthma
Autism
Carpal Tunnel Syndrome and/or wrist pain
Depression and/or Anxiety
Developmental Delay or Disorder (child only)
Diabetes
Dizziness and/or Fainting
Epilepsy
Eye condition and/or Sight Impairment
Hearing Issue
Heart Condition
High Blood Pressure
Learning Disorder
Low Blood Pressure
Lower Back Pain
Neck Pain
Pelvic Pain and/or Sciatica
Shoulder Pain
Any other medical condition or disability we should be aware of?
Photography Permission & Release I give permission to be photographed, or have my image recorded for digital use including on social media. I understand this may be used to promote the services and classes I am participating in, even if I am no longer participating. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses of new photographs. I agree that this form will remain in effect during the term of my participation. I understand that there will be no payment for my participation.*

1. I have read and fully understand the contents of this form and confirm that my answers are true to the best of my knowledge.
2. I confirm that my participation in the classes taught at and by Anicca Yoga and it's instructors is voluntary.
3. I understand that any advice provided to me by any director, employee or instructor at 4. Anicca Yoga is followed at my own risk.
I willingly declare, understand and accept the following:
4.1.  I have no medical conditions which would prevent me from participating in the classes I will attend or have attended. 
4.2.  I have declared within the past 3 months (or since my most recent birth and/or medical treatment) by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga.
4.3.  If attending with a minor, the minor has been recently declared by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga. 
4.4.  If at any time this changes I will inform you in writing prior to taking any more classes.
5. I, my heirs and legal representatives knowingly and voluntarily waive any future claim I may have against Anicca Yoga or any Director, employee or instructor at Anicca Yoga for any injury, condition, or damages I may sustain from being on your premises, participating in classes or following advice.
6. Any fees or membership dues paid by me are not refundable other than at the sole discretion of Anicca Yoga and as stipulated in the terms and conditions I was provided at the time of booking. In the instance bookings have been made through a third partner I understand that the third party's cancellation and refund policy applies and accept that Anicca Yoga is not responsible for any cancellation or refund. 
7. Anicca Yoga and its employees, contractors and volunteers reserves the right to refuse access and may terminate my membership at any time for any reason. In such event, my compensation is limited to the unused amount if any dues paid.
8. Anicca Yoga is not liable for any loss, theft or damage occurring to any personal property on any premises in which classes are taught including Anicca Yoga studio, third party studios or locations and/or clients home or other location. 
9. We may use some of the information you have provided for the purpose of monitoring, assessing or marketing Anicca Yoga and to inform you of offers, information and other services and products on occasions. 
10. We undertake not to sell or otherwise distribute any personal information of you to third parties.
11. I understand that this contract is subject to California State Law and where applicable the federal Law of the United States of America and United States Court jurisdiction.

12. I have read the above agreement and the waiver and release of liability and fully understand its contents. I voluntarily agree to Anicca Yoga Terms and Conditions. 

Parent or Guardian's Email Address

Email*

Confirm Email*
Would you like to receive further information from us via email?E.G. new classes, live-stream classes
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Questions for Parent/Guardian only

What are you hoping you/your child gain from Parent & Toddler yoga?

Is there any aspect of parenting you would like to change or improve? For example: managing tantrums, dealing with sleep disruption.

Have you practiced yoga in past year? If so, please detail type of class and/or where you practiced.
Have you experienced any of the following conditions in the past year? (females only)
Childbirth (not incl. C-Section)
Childbirth (via C-Section)
Diastasis Recti
Pelvic Floor Issues (including incontinence, prolapse, hypertonic or hypotonic)

Is there anything else you'd like to share and/or ask in preparation for your first class?
Do you regularly participate in any physical/fitness activities?*
No
Yes

If yes, please list physical/fitness activities you currently participate in 2 or more times a month?
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*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Has your Primary Care Provider informed you of any restrictions, contraindications or other concerns that may prevent or inhibit you/your child from practicing yoga?*
Yes
No
Are you/your child currently experiencing any pain, illness and/or other receiving medical treatment of any kind?*
Yes
No

If yes, please detail.
Do you/your child currently have any of the following conditions? ​ (tick all that apply)
Arthritis
Asthma
Autism
Carpal Tunnel Syndrome and/or wrist pain
Depression and/or Anxiety
Developmental Delay or Disorder (child only)
Diabetes
Dizziness and/or Fainting
Epilepsy
Eye condition and/or Sight Impairment
Hearing Issue
Heart Condition
High Blood Pressure
Learning Disorder
Low Blood Pressure
Lower Back Pain
Neck Pain
Pelvic Pain and/or Sciatica
Shoulder Pain
Any other medical condition or disability we should be aware of?
Photography Permission & Release I give permission to be photographed, or have my image recorded for digital use including on social media. I understand this may be used to promote the services and classes I am participating in, even if I am no longer participating. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses of new photographs. I agree that this form will remain in effect during the term of my participation. I understand that there will be no payment for my participation.*

1. I have read and fully understand the contents of this form and confirm that my answers are true to the best of my knowledge.
2. I confirm that my participation in the classes taught at and by Anicca Yoga and it's instructors is voluntary.
3. I understand that any advice provided to me by any director, employee or instructor at 4. Anicca Yoga is followed at my own risk.
I willingly declare, understand and accept the following:
4.1.  I have no medical conditions which would prevent me from participating in the classes I will attend or have attended. 
4.2.  I have declared within the past 3 months (or since my most recent birth and/or medical treatment) by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga.
4.3.  If attending with a minor, the minor has been recently declared by a physician to be in good physical health and capable of performing yoga exercises in a manner consistent with those offered by Anicca Yoga. 
4.4.  If at any time this changes I will inform you in writing prior to taking any more classes.
5. I, my heirs and legal representatives knowingly and voluntarily waive any future claim I may have against Anicca Yoga or any Director, employee or instructor at Anicca Yoga for any injury, condition, or damages I may sustain from being on your premises, participating in classes or following advice.
6. Any fees or membership dues paid by me are not refundable other than at the sole discretion of Anicca Yoga and as stipulated in the terms and conditions I was provided at the time of booking. In the instance bookings have been made through a third partner I understand that the third party's cancellation and refund policy applies and accept that Anicca Yoga is not responsible for any cancellation or refund. 
7. Anicca Yoga and its employees, contractors and volunteers reserves the right to refuse access and may terminate my membership at any time for any reason. In such event, my compensation is limited to the unused amount if any dues paid.
8. Anicca Yoga is not liable for any loss, theft or damage occurring to any personal property on any premises in which classes are taught including Anicca Yoga studio, third party studios or locations and/or clients home or other location. 
9. We may use some of the information you have provided for the purpose of monitoring, assessing or marketing Anicca Yoga and to inform you of offers, information and other services and products on occasions. 
10. We undertake not to sell or otherwise distribute any personal information of you to third parties.
11. I understand that this contract is subject to California State Law and where applicable the federal Law of the United States of America and United States Court jurisdiction.

12. I have read the above agreement and the waiver and release of liability and fully understand its contents. I voluntarily agree to Anicca Yoga Terms and Conditions. 

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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