Please Print, Read, Complete, Sign and Date and bring to class, email, mail or drop off at Studio Mills.  Our mail address is below.

STUDIO MILLS

Registration and Health Profile

 

Name___________________________________________Birthdate:_______________

Address ________________________________________________________________

Phone(s):  Home: _______________Work: _______________Cell: ________________

E-Mail:  Home: ____________________________Work: ________________________

Occupation: _____________________________________________________________

How did you hear about Studio Mills? _______________________________________

Please describe your yoga or past experience with exercise:  How many classes, how long,

with whom, home practice, etc.

________________________________________________________________________

Do you have high or low blood pressure or heart problems?  Explain:_______________

_________________________________________________________________________

Have you had surgery in the past 5 years? _____________________________________

  If so…please describe: ____________________________________________________

Do you have diabetes?  ____________________________________________________

Have you been treated for cancer in the past 5 years? ___________________________

Do you have metal implants, rods, braces or pacemaker?________________________

Please list any injuries past or present. _______________________________________

Anything regarding your health I should know about? ________________________________________________________________________

________________________________________________________________________

Are you pregnant?  ______________If so….due date: ___________________________

 

Liability, Release, Acknowledgement and Waiver

I understand and acknowledge that in yoga, as in other forms of physical exercise, bodywork or self-development, there are inherent risks, including the risk of injury.  I agree that I am voluntarily participating in the programs and related activities offered at Studio Mills, and I assume all risks of injury, illness or death.  Because yoga, physical exercise, bodywork and some self-improvement techniques can be strenuous and subject to risk of serious injury, I understand that I should consult with my doctor before participating in any exercise activity, including those offered at Studio Mills.
I acknowledge that I have carefully read this, “Liability, Release, Acknowledgement and Waiver” and fully understand that it is a release of all liabilities of any type or kind.  I expressly release and fully discharge Studio Mills and all of its affiliates, employees, agents, instructors, representatives, successor and assigns, from any and all claims or causes of action of any kind or nature that I may now or hereafter have against any or all of them: and I agree that I have voluntarily given up and waived any right that I may otherwise have to bring legal action of any kind against Studio Mills, or any of its affiliates, employees, agents, instructors, representatives, successors or assigns, for personal injury or property damage.  This Liability, Release, Acknowledgement and Waiver of liability includes, without limitation, all injuries of any type, kind or nature that my occur, directly or indirectly, as a result of my instruction, training, supervision, or dietary recommendations by Studio Mills, the agents instructors, representatives, successors, or assigns, my slipping and or falling with participating any activity on the premises, including adjacent sidewalks and parking areas.  In addition, Studio Mills is not responsible for any loss of, or damage to, my personal property.
If any portion of this release from liability shall be deemed by a Court or competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from.
By signing this release, I acknowledge that I understand its content and this release cannot be modified orally.

 Signature: ______________________________________Date: ______________________________