Sacred Well Yoga Studio LLC Application

Sacred Well Yoga Studio and Healing Center

Application

NAME__________________________________________________________________________

ADDRESS_______________________________________________________________________

CITY________________________________________________ZIP_______________________

HOME PHONE_________________________________WORK_______________________________

EMAIL____________________________________

CLASS CHOICE

CLASS:_____________________________________DAY_________________TIME____________

Known physical limitations___________________________________________________________________

I hereby stipulate that I am physically sound to proceed with instruction in Yoga or other physical disciplines. It is further agreed that all exercises and lessons shall be undertaken at my sole risk and that the Sacred Well Yoga Studio LLC shall not be liable for injuries or damages to my person or property arising out of, or connected with, the use of services or facilities of the Sacred Well Yoga Studio LLC or the premises in which the same are located. I do hereby forever release and discharge the Sacred Well Yoga Studio LLC from all such causes of action.

I also understand that my deposit and tuition are non-refundable, unless the class is cancelled or I have extenuating circumstances and neither may be applied toward any future semester of classes.

Amount Enclosed__________________ Date__________________________

Signature____________________________________________________________
(Parental Signature Required for Minors)

Mail or bring application and payment to:

Sacred Well Yoga Studio LLC
450 W. Broad Street, Suite 319
Falls Church, VA 22046

Telephone: (703) 989-8316