New Student Form

Please take a moment to completely fill out this form before you attend class - THANK YOU !

Legal Name & Address

Legal First Name

Middle Initial

Legal Last Name

Preferred first name, different from legal name (optional)

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Contact Information

Phone

May we send you email notices about upcoming events, promos, schedule chages, etc?

Other Info

Birthday

Did you hear of us another way?

Emergency Contact

Emergency Contact Name

Emergency Contact Phone

Relationship

I confirm that the information given in this form is true

Release of Liability

I authorize the collection and use of the above personal information as is required for legal, safety, and administrative purpose. I understand that all my personal information is confidential and will not be released without my signed consent. I understand that classes at CITYOGA may be physically strenuous and I voluntarily participate in them with full knowledge that there is a risk of personal injury, property loss, or death. I agree to be gentle with myself and I agree that neither I, my heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against CITYOGA or its members for any personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise.

Date

Initials

Your Signature

Thanks for submitting!