A Create New Yoga OM Account INSTRUCTIONS: Fill in all required ‘*‘ fields. Please check your email and look for a confirmation message from Yoga OM. Your account will not be active until you confirm your account. Step 1 of 4 0% Name First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone (Home)Phone (Cell)Phone (Work)Email Please ensure you have included a valid email addressWould you like to recieve our Newsletter?YesNoGenderMaleFemalePrefer Not to AnswerBirthday DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Tell us a little about you:Name of class you are taking today?How did you find out about Yoga OM?Why have you come to this yoga class? Please explain breifly?Do you have previous expreance with yoga? If so, explain.What types of physical activities do you participate in and how often? Medical Information:Emergency Contact PersonEmergency Contact NumberDo you have any medical condition which might prevent you from exercising or participating in physical activities? If so, explain:Do you have a diagnosis by a physician? If so, explainAre you taking any medications at this time? If so, explain Terms of Service1. That I am participating in the Yoga Class, Nutrition Health Program or related Workshop offered by Yoga.Om during which I will receive information and instruction about Yoga and Health. I recognize that this requires physical exertion which may be strenuous and may cause physical injury and/or side effects from 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 any Yoga Class, Health Program or related Workshop (collectively referred to as “Activity”). I represent and warrant that I am physically fit and that I have no medical condition which would prevent my full participation in any Activity in which I participate. I understand that it is my responsibility to ascertain that I am capable of participating in any such Activity, and that I should continue to keep Yoga.Om fully informed of any physical or other condition or disability which would prevent or limit my participation in any Activity. 3. In consideration of being permitted to participate in any Activity that I sign up for, I AGREE TO , AND, I ASSUME FULL RESPONSIBILITY FOR ALL RISKS, INJURIES OR DAMAGES, KNOWN OR UNKNOWN, WHICH I MIGHT INCUR AS A RESULT OF PARTICIPATING IN ANY SUCH ACTIVITY. 4. In consideration of being permitted to participate in any Activity that I sign up for, I hereby fully and forever release and hold harmless Yoga.OM, its employees, owners, and agents (collectively called the “Releasees”) from and against any and all liability to me, my heirs executors, personal representatives, administrators and/or assigns, for any and all claims, demands, causes of action, losses and damages of any kind whatsoever on account of any injury including loss, injury, death or damage to my person and/or any property or to any other person and/or their property, caused or alleged to be caused by any action or inaction of any of the Releasees. I hereby waive any right to sue any of the Releasees for any injuries or damages I may incur whether known or unknown resulting from my participation in any Activity. 5. I understand and agree this document is to be binding on myself, my heirs, personal representatives, executors, administrators and assigns. 6. I AGREE TO DISCUSS ANY HEALTH RESTRICTIONS, QUESTIONS OR CONCERNS WITH THE INSTRUCTOR PRIOR TO ANY CLASS, PROGRAM OR WORKSHOP IN WHICH I AM ENROLLED.Terms of Services Agreement* 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. Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.