Today’s Date: _________________
Teacher: _____________________ Ever been a student at GBY before? Yes No
My signature below indicates I understand that Yoga includes physical movements. If I experience any pain or
discomfort, I will listen to my body, adjust the posture and ask for support from the teacher. Yoga is not a
substitute for medical attention, examination, diagnosis or treatment. I affirm that I alone am responsible to
decide whether to practice yoga. I hereby agree to irrevocably release and waive any claims that I have now or
hereafter may have against Sandy Hicks, Wendy Stoddard, Grounded By Yoga Studios & Yoga Teacher Training
Center LLC (GBY) or any other instructor. My email is provided below as consent to receive studio news &
updates once per month. Signed: ______________________________________
Last Name _____________________________________________________First Name ________________________________________
Email address_________________________________________________ Phone______________________________________________
Address ____________________________________________________________________________________________________________
Date of Birth__________________________ How did you hear about us?______________________________________________
Briefly state why you chose to incorporate Yoga into your
life?_________________________________________________________________________________ _______________________________
What is your experience with yoga? _______________________________________________________________________________
Medical Concerns? (can’t be on knees, recent surgeries, pregnant, HBP, joint replacement, etc)
______________________________________________________________________________________________________________________
Your instructor is trained to lightly assist you with various hands on approaches. This is a very gentle touch. Is it
ok if your instructor provides assists? YES NO
What are you purchasing today?
_____ Drop In $12
_____10 Classes for $95 (10 Week Expiry)
_____10 Classes for $105 (3 Month Expiry)
_____10 Classes for $115 (4 Month Expiry)
_____3 Months for $385
_____6 Months for $690
Other: ________________________________________
EARN REWARDS! Starting very soon all active students will have the opportunity to earn rewards
several simple ways! These rewards convert to savings for each package you buy! Stay tuned to our
newsletter for the initial announcement so you don’t miss out. As always, you can also
earn $20 on your account for referring someone and they commit to a 10 pack, 3
month or 6 month program!