Maya Whole Health Studio

Class Registration / Waiver of Liability

Name ________________________________________________________ Address ______________________________________________________ City ________________________ State __________ Zip ______________ Primary Phone _______________ Secondary Phone ___________________ Email (reminders/cancellations/notifications): _____________________________________________________________
Would you like to receive our monthly e-newsletter that includes specials, promotions, and announcements about special events, new classes, etc? Yes _____ No _____

Birthdate ________ / _________/___________ Emergency Contact Name: ________________Phone:__________________ How did you discover Maya? ______________________________________
In consideration of being permitted to participate in these classes, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participation in these activities. _______ I am fully aware of risks and hazards involved in any physical exertion and movement activity, and I hereby voluntarily and expressly waive any claim I may have against Maya Whole Health Renton LLC and any agents of this organization for injury or damages that I may sustain as a result of participating in these activities. _______ I represent and warrant that I have no known medical condition that would prevent or contraindicate my participation in any class/workshop/event in which I choose to participate at Maya Whole Health Studio. _______ I understand that any information provided by any employee, contractor, or other agent for Maya Whole Health Studio regarding my fitness for any activity DOES NOT serve as release from my responsibility to engage and consult with appropriate health care practitioner(s) prior to and regarding my participation in these classes and to adhere to recommendations provided by any medical or other health care provider. _______ On behalf of myself and all heirs or legal representatives, I hereby release, waive, discharge, and hold harmless Maya Whole Health Studio LLC and its agents for any injury, death, or other unintended outcome associated with my participation in any class, workshop, or other activity on the premises. I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the term and conditions stated above. Signature of Participant:___________________________ Date ________________ Signature of Parent of Guardian if under the age of 16: _______________________________________________ Date ________________

1322 Lake Washington Blvd N Suite 3 Renton, WA 98056 Direct 425.271.0200 :: Fax 206.309.3383 :: www.mayawholehealth.com