Integral Yoga® Center of Richmond HOME WHAT'S YOGA SCHEDULE REGISTRATION ARCHIVE TEACHERS YOGA LINKS WORKSHOPS E-MAIL US REGISTRATION & WAIVER OF LIABILITY FORMS Please read the registration instructions carefully before mailing the registration form and making out checks. The mailing address for registration will vary depending on the course location and sponsor. Checks are made out to the course sponsors listed on the registration instructions. Please read the class policies before signing the waiver of liability form. Registration Form Registrant's First Name:  Middle Initial:      Last Name:  Age:      E-Mail:  Street Address:  City:      State:  Select a State Alabama, AL Alaska, AK Arizona, AZ Arkansas, AR California, CA Colorado, CO Connecticut, CT Delaware, DE District of Columbia Florida, FL Georgia, GA Hawaii, HI Idaho, ID Illinois, IL Indiana, IN Iowa, IA Kansas, KS Kentucky, KY Louisana, LA Maine, ME Maryland, MD Massachusetts, MA Michigan, MI Minnesota, MN Mississippi, MS Missouri, MO Montana, MT Nebraska, NE Nevada, NV New Hampshire, NH New Jersey, NJ New Mexico, NM New York, NY North Carolina, NC North Dakota, ND Ohio, OH Oklahoma, OK Oregon, OR Pennsylvania, PA Rhode Island, RI South Carolina, SC South Dakota, SD Tennessee, TN Texas, TX Utah, UT Vermont, VT Virginia, VA Washington, WA Wisconsin, WI Wyoming, WY Zip Code:      Home Phone:  Work Phone:  Employer:      Position:  Class Selection: Agreement of Release and Waiver of Liability Form I,    hereby agree to the following: 1. That I am participating in the Yoga Class/Workshop, offered by the Integral Yoga Center of Richmond, held at  Select a Location (blank line for unlisted) Still Water Zen Center Unitarian Church Advanced Manual Therapies  , starting on    , called (Class Name)  , taught by Select an Instructor (blank line for unlisted) Nora Vimala Pozzi  , during which I will receive information and instruction about yoga and health. I recognize that yoga may require some physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. 2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Yoga Class or Workshop. I represent and warrant that I am physically fit and I have no medical condition which would prevent my full participation in theYoga Class/Workshop. 3. In consideration of being permitted to participate in the Yoga Class or Workshop, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the program. 4. In further consideration of being permitted to participate in the Yoga Class/Workshop, I knowingly, voluntarily and expressly waive any claim I may have against the Integral Yoga Center of Richmond, its instructors and staff, Integral Yoga International, Advanced Manual Therapies and its owners, and class/workshop Sponsor, Select a Sponsor Not Applicable: No Sponsor Still Water Zen Center Center of Integrative Medicine First Unitarian Church   for any injury or damages that I may sustain as a result of participating in the program. 5. I, my heirs or legal representatives, forever release, waive, discharge and covenant negligence or other acts. I have read the above release and waiver of liability and fully understand its contents as well as the Refund/Cancellation and Make-up Class Policies. I voluntarily agree to the terms and conditions stated above. REGISTRANT'S SIGNATURE: _________________________________________________________ DATE:    If registrant is under 18 a legal guardian's authorization is required: AS LEGAL GUARDIAN OF     I CONSENT TO THE ABOVE TERMS AND CONDITIONS. GUARDIAN'S SIGNATURE: ___________________________________________________________ WITNESSED BY: ___________________________________________________________________ Please indicate any physical conditions or disabilities, current or chronic, which might limit participation in this class, any medication taken at this time or/any allergies known: