______ Street Address

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Registration Form Are you: ☐ Pregnant

ENTERED/ID

PLEASE Write Legibly .

☐ 14 years or younger

☐ Under 18 years of age

☐ Certified Bikram Yoga Teacher

Name: ____________________________________________________________ Date of Birth: ____/____/_______ Street Address: _____________________________________________________ City: _____________________________ State: __________ Zip: _____________ Phone Number: _______________________ Other Phone: __________________

$__________ MEMBERSHIP: INTRO DI COMP PAYMENT CC $ OTHER WE Received ...

Email Address:

Do you have any medical concerns? Yes / No If yes, please explain: ___________________________ _____________________________________________ _____________________________________________ Have you ever done Bikram Yoga? ________________ If yes, where? _____________________________ Primary Reason? (Circle one) Flexibility Improve Health Lose Weight Other: __________________________________

I hereby agree to the following: 1. I am aware that participation in a sport or Yoga may result in accident or injury, and I accept the risks connected with the participation in a sport or Yoga. I represent that Member is in good health and suffers from no physical impairment that would limit my use of Bikram Yoga Meyerland Plaza's facility. I acknowledge that Bikram Yoga Meyerland Plaza has not and will not tender any medical services including medical diagnosis of Member's physical conditions. Bikram Yoga Meyerland Plaza, its owners, employees, and agents shall not be sued or held liable for any claim, demand, cause of action of any kind whatsoever for or on account of death, personal injury, accident, damage, cost, or loss of any kind resulting from or related to Member's use of the facility or participation in any sport, exercise, or activity within the club and its surrounding premises. I also agree to hold harmless on Bikram Yoga Meyerland Plaza and I release and discharge Bikram Yoga Meyerland Plaza from any and all claims and liabilities arising out of any negligence whatsoever while I am on the premises participating, or not. I assume full responsibility for all risks, whether foreseeable or not, connected with my presence at the facilities or involvement in activities of Bikram Yoga Meyerland Plaza. I have read the above release; fully understand its contents, and waiver complete liability. 2. Personal Property. I agree that if I bring personal property to the Property, and I store or leave any personal property at the Property, in the facility and surrounding, I will do so at my own risk and that none of the Released Parties above shall have any liability in the event of loss, damage, unauthorized use (by any person other than a Released Party), theft, or injury resulting from the personal property. Personal property includes all vehicles; Bikram Yoga Meyerland Plaza will not be subject to pay for any cost related to the above events, nor will we be responsible for any towing or ticket fees that you may acquire. 3. Guardianship. I fully understand while on the premises and property of Bikram Yoga Meyerland Plaza, my child or dependent (the undersigned), for

Date: __________________

Ana

How did you hear about us? (Circle one) Flyer Internet Ad Drive By

Another Client? (First and Last name of referring client) ___________________________________________

Emergency Contact Name: _______________________________________ Phone: (______) _________-__________ Relationship: ____________________________

themselves, and/or being the legal and acting guardian of child(s) on premises, acting for themselves and/or on behalf of the participant(s), participating or not, release and hold harmless on Bikram Yoga Meyerland Plaza, its owners, employees, and agents of and from any and all liability, claims, demands, and causes of action, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the non-participant waiting for you, while in or upon the premises which Bikram Yoga Meyerland Plaza is conducted, or any premises of Bikram Yoga Meyerland Plaza. 4. Service. I acknowledge that I am subject to pay for all dues incurred by me obligated to Bikram Yoga Meyerland Plaza and understand dues are paid in advance for the following month. I accept Bikram Yoga Meyerland Plaza has the right to refuse service to anyone, including me, for any reason. 5. Refunds. I acknowledge that Bikram Yoga Meyerland Plaza does not give any refunds, exchanges, extensions, or transfers on processed class membership packages. 6. Photo/ Video Release. I authorize Bikram Yoga Meyerland Plaza to reproduce and/or publish photographs and/or video that may pertain to me and my property- including my image, likeness and/or voice without compensation. I understand that this material may also appear on Bikram Yoga Meyerland Plaza’s Web Page and social media. NOTICE: This is a legally binding agreement, by signing this agreement, you contractually agree to never bring a court action to recover compensation or obtain any other remedy for any injury to yourself or your property or for your death caused by your presence or participation at Bikram Yoga Meyerland Plaza. I HAVE READ THIS RELEASE OF LIABILITY AND NEGLIGENCE AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Signature: ____________________________________________

If participant is under 18: AS LEGAL GUARDIAN OF __________________________________, I CONSENT TO THE ABOVE TERMS AND CONDITIONS. Date: __________________

Signature: ____________________________________________