10702 Main St. Mantua, OH 44255

(330) 931-2532

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Healthy Hearts Wellness and Yoga

Please complete this form to register for our yoga class. We're excited to have you!

**Please note, all of the information on this form is kept confidential.

Registrant details:

First Name *

Last Name *

Email *

Phone *

Date of birth *

Address

Street Address *

City *

State *

Country *

Postal code *

Limitations/Injuries

Emergency Contact

Name For Emergency Contact

Phone Number *

Waiver

If at any point during the class, you feel discomfort or strain, gently come out of the pose. You may rest at any time during class. It is important in yoga that you listen to your body and respect it’s limits on any given day. I, the undersigned, understand that yoga is not a substitute for medical attention, examination, diagnosis, or treatment. I should consult a physician prior to beginning any activity program, including yoga. I recognize that it is my responsibility to notify my teacher of any serious illness or injury before every yoga class. I will not perform any poses to the extend of strain or pain. I accept that neither the instructor, nor the hosting facility, is liable for any injury, or damages, to a person or property, resulting from taking the class. *

Agree

Today's Date *

Signature *

Clear

If Under 18, Parent/Guardian Signature Here

Clear

I agree to privacy policy and terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

10702 Main St. Mantua, OH 44255

(330) 931-2532