EmailMe Form - Beginners' Qigong for Health & Well-Being

Name *

First Last

Home Phone

### - ### - ####

Email *

Mobile Phone

### - ### - ####

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Class fee is $80/10 Weeks. Please indicate below if you are interested in hearing more about available tuition assistance.

How did you first hear about this class? *

This class will be offered on Wednesday from 6-7 p.m.

Informed Consent and Hold Harmless/Release Agreement:
I understand that participation in exercise 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. I understand that class participants will be shown multiple modifications for each exercise and that only I know best which modifications will be the safest for me. I understand this class is not about competition and that all participants should strive to comfortably self-challenge while exercising at the level appropriate to each individual's skill set and health. By printing my name below, I release the Wil-‐Mar Neighborhood Center and Scott Martin from any and all claims of liability arising out of my 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?