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

Student Information:!


! 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.!


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.!


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

! ! Print: ____________________________________________! !


Signature: _________________________________________ Date: _____________________