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1. Last name, first name

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2. Email address

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3. Share a little of what motivated you to register for this retreat. (optional)

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4. Risks in physical activity:
Before undertaking any exercise program one should consult a physician. I understand that there are
inherent risks and benefits associated with any exercise program. By signing below I understand the risks
and any resulting injury that could arise out of such risk due to participating in this exercise program/yoga
classes.

Assumption of Responsibility:
If I feel in any way that I cannot meet the demands of the class, it is my responsibility to alter, modify, or
discontinue the class. I assume the responsibility for my own personal safety and health as I participate in
the exercise/yoga program/classes.

By signing below, you agree and accept the responsibility to alter, modify or discontinue movement and ensure your personal safety and health. 

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5. If you have questions or need accommodations, please contact Rebecca Allen Davis.  rebeccallendavis@gmail.com 

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6. Date 

Date

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