New Student Form

 

PLEASE TAKE A MOMENT TO COMPLETELY FILL OUT THIS FORM-Thank You-

(Please Read!) Release of Liability: In signing below I agree that Bamboo Yoga Studio and Bodywork Center is in no way responsible for the safekeeping of my personal belongings while I attend class. I understand that classes at Bamboo Yoga Studio and Bodywork Center may be physically strenuous and I voluntarily participate in them with full knowledge that there is risk of personal injury, property loss or death. I agree that neither I, my heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against Bamboo Yoga Studio and Bodywork Center or its members for any personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise.

Release of Liability - Signature __________________ Legal Guardian (if Under 18) ____________________

NAME & ADDRESS

Last Name       ________________________

First Name      ________________________

Address           ________________________

City                 ________________________ State ____ Zip ____________

 

PHONE #

Hm Ph.             (____)______________

Cell Phone       (____)______________

Work Phone    (____)______________ Ext_____

 

OTHER INFO

Birth date       ____/____/_____

How did you find out about us? (circle one)

Friend ________?	Internet	driving by	Eagle Newspaper	Coronado Lifestyle
Coronado Phone book	Coronado Pocket Map	Bamboo Staff _________?	Flyer	Other

Email address _______________________________ (very important!)

May we send you email notices about events, specials, etc.? Yes No

MEDICAL ISSUES, INJURIES AND CONCERNS________________________________________

___________________________________________________________________________

EMERGENCY CONTACT

Name    ___________________ Phone # (____)______________ Relationship ______________

 

INTERESTS (circle all that apply)

Massage	Spinning	Pilates	Workshops	Retreats	Meditations
Pre/Post Natal	Chanting	Belly Dancing	Weight Loss	Back-Clinics	Restorative Yoga
Hatha Yoga	Intro to Yoga	Beginning yoga	Senior Yoga	Flow Yoga	Astanga Yoga
Iyengar Yoga	Kundalini Yoga	NIA	Feng Shui	Acupuncture	Other________