Last Name: First Name:
City: State: Zip:
Who referred you?
Yoga Experience: Beginner (0-6 mos) Intermediate (6 mos-2yrs) Advanced (3 yrs +)
Check Weekly Exercise Frequency: 0 1-2 times 3-4 times Daily
Name of Gym or Other Exercise Facility You Frequent: or None
Explain any current or chronic medical condition or limitation you have and furnish a letter from your physician authorizing Yoga or stating any exercise limitations:
I am applying to attend Yoga classes at BreatheRock Group, Inc., which I understand is an independent operator licensed to use the trademark “Wanderlust Yoga” (referred to herein as “Wanderlust”). As an inducement to Wanderlust to accept me as a Yoga student, I represent and agree with Wanderlust as follows:
(1) I will use my best efforts to follow all instructions given to me by Wanderlust authorized instructors as to when and how to perform, and how not to perform, Yoga exercises. I understand the practice of Yoga and group exercise activities may expose me to risk of personal injury, disease, or death and I knowingly and willingly assume such risks.
(2) I have been examined by a licensed Physician within the past six months and have been found by such physician to be in good health and fully able to perform all Yoga exercises, which I am to learn and perform during my enrollment with Wanderlust.
(3) I acknowledge and agree that I will receive instruction in Yoga theory and exercise only. I hereby release and hold harmless Wanderlust its employees, officers, directors, shareholders, and contract trainers and teachers for any personal injury, including but not limited to bodily injury, disease, disability, death, mental anguish, or consequential loss of any kind arising out of my participation in any Wanderlust class event or activity, as well as any damage to or theft of personal property on or away from Wanderlusts premises,. This release and hold harmless is intended to be effective for myself as well as my heirs, executors, administrators and family members.
(4) If I am now pregnant, or if I become pregnant, I will not attend a yoga class until I have discussed the potential risks to me and my unborn child/fetus with my obstetrician. I agree that I will follow my obstetrician's recommendations and on behalf of myself, my heirs, spouse or other interested party hold harmless Wanderlust for any possible injury to myself or my unborn child/fetus.
(5) If I am under 18 years of age, I warrant that I have disclosed my age to Wanderlust and, in addition to my signature, have provided the signature of my parent or legal custodian or guardian below.
(6) I acknowledge that all equipment and services at Wanderlust, including classes, times, disciplines and teachers, are subject to change without notice.
(7) Registration fees and tuition for classes paid to Wanderlust are not refundable.
(8) Any provision not in conformity with the laws of Texas is hereby severed from this contract and the remaining provisions remain enforceable. I agree that any suit filed against the Company must be filed in in a state or federal court located in Travis County, Texas and must be decided in accordance with the laws of the State of Texas.
I acknowledge that the performance of the services by Wanderlust is conditioned on payment of the tuition and my agreement to these terms.