Jessica Mollet, Yoga Instructor for Breathing Mountain Yoga in Raleigh, NC

BREATHING MOUNTAIN YOGA

Registration
Please print this form, fill it out and mail to: 501 Mial Street, Raleigh, NC 27608 OR provide the information listed below in an email to jessica_mollet@yahoo.com and mail checks payable to Jessica Mollet.

Yes, please register me for the following Hatha Yoga class(es):
__ Mondays, 5:30 - 7 pm , Level I & II
__ Tuesdays, 5:30 – 7 pm, Level I
__ Wednesdays, 5:30 - 7 pm, Level I & II
__ Thursdays, 5:30 – 7 pm, Level II

Cost:
__ 8 classes in 8 weeks for $90
__ 16 classes in 8 weeks for $160
__ Drop-in: $15
__ Individualized Yoga Therapy $50 ($65 for first assessment and consultation)

Name: _______________________________________ Phone: __________________________________

Email: _____________________________ Date of Birth (mm/dd): ________________________________

Address: _________________________ Emergency Name & Phone No.: __________________________

Have you done yoga before? If so, what kind? How long? _______________________________________

What are your reasons for practicing yoga?__________________________________________________

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What other types of physical activities do you do? ____________________________________________

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Do you have any physical limitations that I need to know? ______________________________________

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Do you have any environmental allergies or chemical sensitivities that I should know? ________________

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*** Please refrain from wearing any scented perfume/cologne/oils to class, as some participants are highly sensitive.

WAIVER

I _________________________________(print name) understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, adjust the posture and ask for support from the teacher. I will continue to breathe smoothly.

Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I affirm that I alone am responsible to decide whether to practice yoga. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against Jessica Mollet.

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Signature of student Date