NAME__________________________________________________________________________

ADDRESS_______________________________________________________________________

CITY________________________________________________ZIP_______________________

HOME PHONE_________________________________WORK_______________________________

EMAIL__________________________________________________

WORKSHOP SELECTIONS

Workshop:____________________________________________________________Fee $____________

Workshop:____________________________________________________________Fee $____________

Workshop:____________________________________________________________Fee $____________

Workshop:____________________________________________________________Fee $____________

                                                                                                          TOTAL $____________

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.

Amount Enclosed (check or cash only) __________________                 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

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