This registration form collects contact and medical information from students and requires parents/guardians to sign a liability waiver. It requests the student's name and age, address, phone numbers, emergency contact, and known medical issues. Parents must provide their name and sign to acknowledge understanding of the waiver, which releases the instructor from any liability for injuries incurred during yoga or skating classes, and allows use of photos/videos for advertising. It also asks for payment details and how the student heard about the class.

1. www.annagoehner.blog.com
REGISTRATION FORM
Student name and age:
Address:
Home Phone #:
Mobile Phone #:
E-mail:
Emergency contact:
Parent/Guardian:
Please list all known allergies, physical limitations, concerns and goals:
Which class attending:
Form of payment and amount:
How did you hear about this class?
Liability disclaimer: please read carefully
I hereby affirm that my daughter or son,
_______________________, is in good physical condition and does not suffer from any disability that would
prevent or limit participation in the Yoga or Skating classes taught by Anna Goehner. I
_______________________ , the parent of ______________________, hereby release Anna Goehner from any
claims, demands and causes of action arising from my son/daughters participation in the above stated
classes. I hereby release Anna Goehner from any liability now or in the future for any injuries, loss or
damage that may result due to participation in these classes offered by Anna Goehner. I also
understand that photos and videos may be taken throughout the class session and these images may
be published or used for advertising and promotional purposes by Anna Goehner. I understand I will not
be able to protest any such use or receive compensation of any type for use of these pictures. By
signing, I hereby affirm that I have read & fully understand & agree with the above waiver and have
read & fully understood the class policies.
Parent/Guardian’s signature:__________________________________ Date:____________