Bala-yogini CONFIDENTIAL intake form

New Client Waiver Form

Students Name

Name

Gender

DOB

Parents Name

Name

Phone Number

Address

City

Province

Postal Code

Emergency Contact

Emergency Contact Number

Help Us Get To Know Your Child Better?

Is there anything special about your child that the yoga teacher should know? (likes, dislikes, behavior issues etc?)

List all known allergies:

I understand that Bala-yogini is committed to protecting the privacy of my child and will not use any identifying information such as their name, address, or contact details. Furthermore, I acknowledge that I have read and understood the terms and conditions of the promotion which outline how my consent is used for promotional purposes only. I give permission for Lyn and Bala-yogini my full permission to capture and use my child's image for the promotion of kids yoga classes and teaching seminars.

Yes: I give permission No: I do not give permission

Acknowledgement

I hereby assume full responsibility for any and all risks, injuries or damages, known or unknown, which my child may incur as a result of participating in the Bala-yogini program. I hereby release, waive and forever discharge Bala-yogini and its staff from any claims ensuing from such injury or damage. I hereby grant permission to my child to participate in yoga classes or sessions, with the understanding that he/she will take responsibility for his/her own practice, including deciding whether to modify poses, rest and not participate in any pose due to discomfort. I acknowledge that it is my responsibility to ensure that my child understands the risks involved. It is further understood that Bala-yogini shall not be liable for any act or omission of the instructors. I acknowledge and agree that Lovely Lyn Mercado, its agents and independent contractors shall not be held responsible for any claims brought against them resulting from my child’s participation in this yoga program. Submitting form states my full acceptance with this agreement.

Bala-yogini CONFIDENTIAL intake form

New Client Waiver Form

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