Raleigh Yoga Center

Confidential Information and Release
* All Fields are Required*
*Last Name
*First Name
*Phone Day
*Phone Evening
*Address
Apartment Number
*City
*State
*Zip
*E-Mail
*Date of Birth
(mm/dd/yy)
*Previous Yoga Experience


*Other Form of Regular Exercise
*Physical Problems or Areas of Concern
*Are you under any form of treatment for anything? If so, what condition and treatment?
*What attracted you to Yoga?
*What are your goals in studying Yoga?
*How did you hear about this program?
 

I agree to take full responsibility for not exceeding my limits in the study and practice of Yoga and for any injury or discomfort I might experience in the study and practice of Yoga.

It is my responsibility to ascertain that there is no medical reason why I should not study and practice Yoga.

I waive any claim that I might have at any time for injury of any sort against the Raleigh Yoga Center and any instructors at the Raleigh Yoga Center or entity involved therewith.
 
*Signed: Date: 7/4/2008
Please do not print and mail - Just Submit by clicking "Submit this Form"