Camp registration form for next Yoga camp: September 30,2011
REGISTRATION AND INSURANCE INFORMATION
_______________________________
CAMPER NAME/ PHONE NO.
PARENTS NAME(S) EMAIL CONTACT
STREET ADDRESS CITY / STATE / ZIPCODE
EMERGENCY CONTACT EMERGENCY CONTACT PHONE NOS.
THE FOLLOWING SECTION MUST BE COMPLETED BY A PARENT OR LEGAL GUARDIAN OF ANY CAMPER UNDER 18 YEARS OF AGE:
CAMPER’S SCHOOL / GRADE CAMPER’S SEX / DATE OF BIRTH
MEDICAL INSURANCE CARRIER / POLICY NO. PRIMARY PHYSICIAN NAME
PHONE
SPECIAL MEDICAL CONDITIONS / NEEDS: (INDICATE “NONE” IF NONE EXIST)
EQUIPMENT
All campers are required to provide their own mats and towels. Mats are available for purchase from Inner Power Store. House mats are available for an additional fee of 2.00per class.
FEES
There is a one time non refundable Omwork Club registration fee of 20.00 which entitles you to all Omwork Club member benefits.
30.00 for each 2 hour session.
PARTICIPATION AGREEMENT & LIABILITY WAIVER
In consideration of being allowed to participate in the Omwork Club I agree to the following:
I acknowledge and fully understand that by participating in the practice of yoga I assume risk of injury, including the possibility of permanent disability or death. I further agree on behalf of myself, my heirs, and my personal representatives that Omwork Club their instructors, sponsors, volunteers, other participants, and any and all persons and entities associated with the locations where practices or events are held, shall not be held liable for any injury, loss of life, or other loss or damage occurring as a result of my participation in the program.
I HAVE READ THE ABOVE PARTICIPATION AGREEMENT. I FULLY UNDERSTAND AND AGREE TO ALL OF THE STATED TERMS AND CONDITIONS. I ALSO UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS AGREEMENT, AND SIGN IT FREELY AND VOLUNTARILY.
PARENT/GUARDIAN APPROVAL
MEDICAL ATTENTION: I certify that my child is covered by the insurance policy indicated above. Additionally, I give permission, in my absence, for the emergency medical treatment of my minor child under authorization of the on-site Omwork Club representative.
WAIVER AND RELEASE: As legal guardian or parent of this participant, I hereby certify that I fully understand and accept all the above conditions for permitting my child to participate in the Omwork Club program.
PARENT/GUARDIAN SIGNATURE DATE
PARENT/GUARDIAN PRINTED NAME
Club Membership - …………………………………………………….….… $Free
A.M. Session 10:30 A.M. – 12:30 P.M. …………………….$30.00
P.M. Session 1:30 P.M-3:30 P.M. ……………………….$30.00
FEE PAID $ CASH CHECK DATE
Free lunch if you come to both sessions