REGISTRATION AND HEALTH PROFILE.  Please read, fill out and click "submit" for final registration and health profile so we know who to contact in case of an emergency.

First Name

Last Name

Birthdate

Emergency Contact Info *
Person
Phone
Relation

My Address

Home Phone

Cell Phone

Work Phone

Email

Occupation

How did you hear about this yoga studio?

Please describe your yoga or past experience with exercise: How many classes, how long,with whom, home practice, etc.



Check any and all conditions which apply *

Anxiety

Arthritis

Asthma

Auto Immune

Blood Clots

Breathing Difficulties

Bruise Easily

Cancer

Chronic Pain

Communicable Disease

Depression

Digestion Problems

Fatigue

Heart Condition

Headaches

High/Low Blood Pressure

Menstrual Problems

Migraines

Numbness/Tingling

Open Cuts or Sores

PMS

Pregnant

Rashes

Seizures

Skin Disease

Sleep Disorder

Other__________________________

For each item checked above please briefly describe

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 by Linda 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 by Linda 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 Linda 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 Linda Mills, 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 may occur, directly or indirectly, as a result of my instruction, training, supervision, or dietary recommendations by Linda 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, Linda 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 fullforce 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. E-Sign and Date below. *

Thank you for registering. Prepare for a great class!

Studio Mills 406 N. Main St., Kingston Springs, TN  37082

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