Forms

                                                           AGREEMENT OF RELEASE
                                                           AND WAIVER OF LIABILITY

I, __________________________, hereby agree to the following:

1. That I am participating in the Yoga Classes, Health Programs or Workshops offered by Flo Parker
during which I will receive information and instruction about yoga and health. I recognize that yoga
requires physical exertion, which may be strenuous and may cause physical injury, and I am fully aware
of the risks and hazards involved.

2. I understand that it is my responsibility to consult with a physician prior to and regarding my
participation in the Yoga Classes, Health Programs or Workshops. I represent and warrant that I am
physically fit and I have no medical condition, which would prevent my full participation in the Yoga
Classes, Health Programs or Workshops.

3. In consideration of being permitted to participate in the Yoga Classes, Health Programs or
Workshops, I agree to assume full responsibility for any risks, injuries or damages, known or unknown,
which I might incur as a result of participating in the program.

4. In further consideration of being permitted to participate in the Yoga Classes, Health Programs
and Workshops, I knowingly, voluntarily and expressly waive any claim I may have against Flo Parker
for injury or damages that I may sustain as a result of participating in the program.

5. I, my heirs or legal representatives forever release, waive, discharge and covenant not to sue
Flo Parker for any injury or death caused by their negligence or other acts.

I have read the above release and waiver of liability and fully understand its contents. I voluntarily
agree to the terms and conditions stated above.

____________                        __________________________________________
DATE                                SIGNATURE OF PARTICIPANT

If participant is under 18:

AS LEGAL GUARDIAN OF ____________________, I CONSENT TO THE ABOVE TERMS AND
CONDITIONS.

____________                        _________________________________________
DATE                                Signature of Parent/Guardian of Participant

	Registration Form Hatha Yoga Date: _______ Level: _______________ Last Name: _______________________________ First Name:______________________________ Address: ______________________________________ City: ______________________________ State: _______ Zip Code: ______ Home Ph: ___________ Work.Ph: ___________ Person to contact in case of emergency: _________________________ Emergency Ph: _____________ Your Your Age: ________ Occupation: ___________ Email: ______________________ Hatha Yoga experience: ____________Style(s): (Circle all that apply) Iyengar, Ashtanga, Kundalini, Sivananda, Kripalu, Bikram, Pilates, Integral, Thai, Egyptian, Traditional, Other Where: ________________________________ How long:__________________________________ Yoga for Beginners (teacher’s use only): ________________________________________________ ________________ _________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Do you have any neck/back injuries or special problems/restrictions that I need to know about? _________________________________________________________________________________ _________________________________________________________________________________ Do you have any of the following? Check all that apply: MS _____Parkinsons_____Diabetes______ High Blood Pressure ____Heart Disease______ Low Blood Pressure_____Glaucoma_____Detached Retina_____Arthritis_____Fibromyalgia__ Recent injuries_____ Any restrictions in movement/breath that your doctor has given you, if so, what are they_______________________________________________________________ For MS students: What are your primary symptoms: Balance___ Vision_____Body temp_____ Tremors_____Speech____Bowel_____Bladder_____ Coordination_____ When was your most recent relapse? ___________________ **Ladies Only: Are you now, or do you suspect you might be pregnant? No______ Yes______ When is the due date?____________ Does your doctor know you are taking a yoga class?_________ Has he given you any restrictions, I need to know about? What are they?___________________________________


	EXHIBIT “A” CITY OF PEMBROKE PINES WAIVER AND RELEASE OF LIABILITY NOTICE: This form contains a Release and Waiver of Liability and when signed is a contract with legal consequences. PLEASE READ IT CAREFULLY BEFORE SIGNING. TO THE CITY OF PEMBROKE PINES: in consideration of the opportunity afforded to me or my minor child/ward to participate in the activity described herein at ___Pembroke Shores Park, 501 SW 172 Ave. Pembroke Pines, FL 33029___________________ (Name and Address of Facility) I, the undersigned, on behalf of myself or my child/ward named herein, do freely agree to make the following contractual representations and agreements. I, on behalf of myself or my child/ward named herein, acknowledge and understand that participation in the activity involves the risk of serious injury, including permanent disability and/or death and severe social and economic losses. I, on behalf of myself or my child/ward named herein, do hereby knowingly, freely, and voluntarily assume all liability for any damage or injury which may occur as a result of my or my child/ward's participation in such activity and further agree to release, waive, discharge, and covenant not to sue the City of Pembroke Pines, its officers, agents, employees, and volunteers from any and all liability or claims which may be sustained by me, my minor child/ward, or a third party directly or indirectly in conjunction with, or arising out of participation in the activity described herein, whether caused in whole or in part by the negligence of the City of Pembroke Pines or otherwise. I, on behalf of myself or my child/ward, have read the above provision, fully understand its terms, and understand that I, on behalf of myself or my child/ward, have given up substantial rights by signing this waiver and I acknowledge that I signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of any and all liability to the greatest extent allowed by law and I agree that, if any portion of this contract is held to be invalid, the balance, notwithstanding, shall continue in full force and effect. Name of Participant:________________________________ Date: ___________________ Signature (Local Guardian if participant is a Minor): __________________________________ Complete Address: ______________________________________________________________ Day Phone: ____________________________________________________________________ Class Title: _Yoga ____________________ _________________________________________ Instructor's Name: __________Flo Parker__________________________________________.