Todays Date *

MM

DD

YYYY

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday

MM

DD

YYYY

Due Date

If you are pregnant

MM

DD

YYYY

If you have been pregnant before, did you experience any of the following?

Check all that apply

Cesarean section birth

Abdominal Separation (Diastasis Recti)

Episiotomy

Which services are you interested in? *

select all that apply

Private sessions

Group classes

Pre/Postnatal Yoga

LIABILITY- In consideration for being allowed to participate in the activities and programs offered by Yoga instructor Jenna Mitchell at any given facility, to use equipment and props in addition to the payments of any fees and charges, I do hereby waive, release, and forever discharge Jenna Mitchell and the facility where classes and sessions are held from any and all responsibilities or liability from injuries or damages resulting from my participation in the above mentioned activities. I understand and am aware that exercise is a potentially hazardous activity. I expressly assume and accept all risks. I hereby release and agree to hold Jenna Mitchell and the facility where classes and sessions are held harmless from any causes of action, claims, demands, damages, costs, expenses and compensation for damage to myself that may be caused by any act, or failure to act, or that may otherwise arise in any way with any services received. I understand that this release discharges the aforementioned from any liability with respect to bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received. This liability waiver and release extends to all owners, partners and employees. *

I have read, fully understood and voluntarily agree.

MEDICAL CLEARANCE – We recommend you consult with a physician before starting this or any exercise program. If you experience any pain or discomfort during the course of the program, stop exercising immediately and seek medical attention. Pre natal and post natal clients must consult with their physician and have received verbal clearance to perform physical exercise. *

I have read, fully understood and voluntarily agree.

PHOTO RELEASE- Photo Release Jenna may take photographs and/or video of participants in programs and events. With your permission, these photographs or videos may be used for PROMOTIONAL purposes (on website, social media, or in the printed program materials to advertise our programs) I hereby authorize Jenna Mitchell to use this participant’s image for: *

I authorize use

I do not authorize use

TERMS & CONDITIONS – Private sessions require a cancelation notice that is received by e-mail or text within 24 hours from the appointment time. Group classes require a 48-hour cancelation notice. If you do not show or do not cancel or reschedule your class/session within the cancelation period, you will be charged the full rate. All sessions and packages are non-transferrable and non-refundable. *

I have read, fully understood and voluntarily agree.

ELECTRONIC SIGNATURE CONSENT – By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use electronic signature with Jenna Mitchell for any documents will continue until such time you notify us in writing that you no longer wish to use an electronic signature. There’s no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary. *

I have read, fully understood and voluntarily agree.