Amazen Kids Yoga Class Registration First Name: Age: Registering for 6 Week Series: Parents / Guardians Full

Name(s): Mailing Address: City: Home: E-Mail: Medical Information List all known diagnoses, special needs, physical limitations, sensory needs or health conditions: State: Cell: Zip: Work: Preferred Contact Method(s): Home Cell Text Work E-mail Last Name: Date of Birth: Nickname: Female Registering for 12 Week Series: Male

List all medications and supplements your child takes & reason for each: Other Information What do you hope that your child will gain from this series of yoga classes? Are there any special themes that you feel may captivate your childs interest?

Is there anything special about your child that the yoga teacher should know (likes, dislikes, fears, behavior issues, etc.)? How does your child respond in groups? interacts easily tends to be shy tends to act out or misbehave in front of groups How did you hear about Amazen Kids Yoga?

Consent, Release of Liability Disclaimer & Notices (please read carefully) I certify that I am the parent or legal guardian of and do hereby consent to his/her participation in the Amazen Kids Yoga classes. I certify that my child is capable of participating in the program and have disclosed all relevant medical information regarding my child. I hereby waive and release Amazen Kids Yoga and their officers, from any and all costs, claims, losses, liabilities or damages arising from or in any way related to, my childs participation in Amazen Kids Yoga. I agree to make no claim, nor to institute any suit, action or proceeding against Amazen Kids Yoga or its officers, relating to any accident, incident or occurrence arising out of, or in connection with, my childs participation in the Amazen Kids Yoga classes. In signing this release, I have reviewed and understand this consent, and release of liability. . I have executed this release on this ___________ day of ______________, 2014. ______________________________ Signature of Parent / Guardian _____________________________________ Printed Name of Parent / Guardian

Consents: 1. In the event of injury to my child, I hereby give consent to contact emergency assistance if needed. 2. I understand that the registration fee is non-refundable and refunds will not be given if a child misses a session. . Parent / Guardian Signature: __________________________________________ Date: ________________ 3. I give permission for my child to be photographed and/or videotaped while participating in the yoga class. Amazen Kids Yoga reserves the right to use these pictures for future corporate publishing with no compensation to the child or guardians. Parent / Guardian Signature: _________________________________ Date: _______________

Make Up Policy Classes cannot be made up or credited for a child's absence from school or withdrawal from school during a yoga session. Classes will only be made up or credited due to weather or if instructor has a change in the class schedule

Parent / Guardian Signature: __________________________________________ Date: ________________