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!