EmailMe Form - Winter 2017 Family Movement

Parent's Name *
First Last
Home Phone
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Email *
Mobile Phone *
### - ### - ####
Child's Name *
First Last
Child's Age *
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
How did you hear about this class? *
Informed Consent and Hold Harmless/Release Agreement:
I understand that participation in yoga and movement activities involves a certain degree of risk. I have carefully considered the risk involved and I understand that participation in these activities is entirely voluntary. By printing my name below, I release the Wil-‐Mar Neighborhood Center and Chelsea Moten from any and all claims of liability arising out of my child's participation in this class. Photos may be taken during a session and I allow these to be used for educational and marketing purposes. *
I have read and agree to the above statement.
Any comments or questions?