LIABILITY WAIVER 4.2016

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Please read the following and fill out completely.! Print legibly—thank you!!

Student Information:!

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! Name: ______________________________________________ Birthday: ________________! ! Mobile Phone: ________________________________________! ! Zip Code: ___________________ Email: ___________________________________________! ! ! How did you hear about us?! Internet _____ Friend _____ Ad _____!

! ! Emergency Contact Information: ! ! *Class cannot be taken without this information*! ! Name: ________________________________! ! Relationship: ___________________________ Phone: _______________________________! ! !

Liability Waiver:! I certify that, by signing below, the information provided above is correct and complete to the best of my knowledge. I acknowledge that yoga classes may be physically strenuous and I am voluntarily participating with the full knowledge that there is risk of personal injury, property loss and/or death. I agree that Ruby and Pearl’s is in no way responsible for the safekeeping of my personal belongings while I attend class. I, my heirs, assigns and/or legal representatives do hereby waive and release Ruby and Pearl’s and its teachers, assistants, and employees from any and all liability and responsibility for any injury, accident, illness, legal and/or medical fees sustained now or in the future resulting from my participation in any activity or use of equipment. I understand that I am giving up my right to sue or make claims of any kind whatsoever against Ruby and Pearl’s and/or their representatives for any personal injury, property damage/loss and wrongful death, whether caused by negligence or otherwise.!

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I acknowledge that I am signing this agreement voluntarily and intend my signature to be a complete and unconditional release of liability to the greatest extent allowable by law.!

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If you do not wish to receive physical assistance from your instructor, it is your responsibility to inform him/her.!

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Signature: _________________________________________ Date: _____________________