Email

Date of Birth

Your Mobile Phone Number

This information is required in case for any reason we need to contact you at short notice.

Name of Doctor & Contact Number

Emergency Contact Name & Number

What Kind of Sports & Exercises Do You Do?

If YES, For How Long?

Physical Limitations/Injuries:

Please provide as much detail as possible.

None of the above? Tell us how you found us, we'd love to know!

Please describe your scoliosis. What kind of curve? What degree?

When were you first diagnosed?

Have you undergone bracing or surgery?

(If Yes, please indicate which)

Do you have any numbness/pain?

Please describe area/body part

Are there any other injuries or concerns that the instructor should know about?

Are you taking medication or do you have any serious allergies that the instructor should know in case of emergency?

AWARENESS OF RISKS AND RELEASE WAIVER

If at any time during the class, you feel discomfort or strain, gently come out of the posture. You may rest at any time during the class. It is important in yoga that you listen to your body, and respect its limits on any given day. I, the undersigned, understand that these classes are not a substitute for medical attention, examinations, diagnosis, or treatment. I should consult a physician prior to beginning any activity program, including yoga. I recognize that it is my responsibility to notify my teacher of any serious illness or injury before every yoga class. I will not perform any postures to the extent of strain or pain. RELEASE AND WAIVER In consideration of the acceptance of my registration for the activities and programs offered or sponsored by Marta Marta Hop Society* / Twisted Outreach Project for Back Care & Scoliosis (TOPS), I hereby for myself, my heirs, executors, administrators, or any others persons who may claim on my behalf, promise not to sue, and hereby waive, release and discharge Marta Marta Hop Society / TOPS and anyone acting for or on its behalf, from any and all claims of liability for personal injury, illness, loss of life or property damage of any kind or nature, arising out of or sustained in the course of my participation in the activities and programs offered or sponsored by Marta Marta Hop Society / TOPS. This Release and Waiver applies to all claims, foreseen or unforeseen, including negligence and breach of statutory or other duty of care. I agree that Marta Marta Hop Society / TOPS is not responsible in the event of loss, damage, unauthorized use, theft, or injury resulting from and to any personal property that I bring onto the premises. I agree that this Agreement and Release and Waiver is intended to be as broad and inclusive as permitted by law. Any provision found to be invalid or unenforceable by a court shall not affect the validity or enforceability of any other provision. I have read this document carefully and acknowledge that I have complete knowledge and understanding of its contents. I recognize that by signing this document I am waiving certain legal rights, including the right to sue. I am signing this document voluntarily. (Those under 18 years of age must have this form signed by a parent or guardian.) * Marta Marta Hop Society means Marta Marta Productions, Twisted Outreach Project for Back Care & Society, its officers, directors, shareholders, employees, contractors, and instructors.

Thank you FOR your registration!

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