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New Student Registration
Please complete this form to register for classes at the Yoga Institute of Broward.
First Name
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Last Name
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E-mail
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A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.
Confirm e-mail address
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Please re-type your e-mail address to confirm it is accurate.
Date of Birth
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Format: 09/23/2023
Gender
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Female
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Contact Info
Home Address
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United States
Address 1
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City
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State
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Home Phone
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Name
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Relationship
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Phone Number
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Signup Info
Occupation
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Health History
*
List all present physical and mental problems and brief synopsis of past problems. (Indicate diagnosis by health care professionals and your symptoms. We need to know what you are experiencing.)
Have you done yoga before?
*
Yes
No
For how long?
Which style?
Why do you want to start or continue the practice of yoga?
*
How Did You Find Us?
*
Google
Bing
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Referral
Flyer
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Other
Other / Who Referred You
Agreement of Release and Waiver of Liability
I understand and acknowledge the fact that in yoga, as in other forms of exercise, sports, bodywork, or self-development, there exist certain inherent risks. I voluntarily participate in the yoga instruction or other programs offered as a student of the Yoga Institute of Broward and agree to assume full responsibility for all risks, injuries, or damages, known or unknown, which I might incur as a result of participating in the yoga program.
I understand and acknowledge that video classes, whether live or pre-recorded, involve greater risk than instruction in person because the teacher cannot see me and make adjustments or corrections to protect me. In addition to the above, I also assume full responsibility for any risks, injuries or damages to persons whom I allow to view such video instruction.
I understand that it is my responsibility to consult with my health care practitioner prior to and regarding my participation in yoga classes. By signing below, I release Yoga Institute of Broward, Ruth Ann Bradley, and Water Garden Place as well as their agents, tenants, managers, employees, other students and individual instructors from liability, and hold them harmless for any injury to my person, and damage or loss to my property incurred while on the premises at 10400 Griffin Road, Suite 205 Cooper City, FL. 33328, whether caused in or out of class, by negligence or otherwise.
I grant to the Yoga Institute of Broward, its representatives and employees the right to take photographs and videos of me and my property in connection with my participation in yoga classes and activities of the Yoga Institute of Broward. I authorize Yoga Institute of Broward, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that the Yoga Institute of Broward may use such photographs or videos of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, instruction, and web content.
Class Pass Refund Policy
Classes are non-refundable and non-transferable.
I have read, understood and agreed to these terms
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Sign by typing your full name *
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