REGISTRATION FORM

Student Information:

Name (Last, First, Middle Initial):   Date of Birth (00/00/0000):

Home Phone Number:      E-Mail Address:

Mailing Address (Street Name, Number/PO Box):

                         Town/City, State, and Zip Code:

Adult Student - Daytime Phone:   Daytime E-Mail: 

The following must be completed if student is under 18 years of age:

Mother's/Guardian's Name:     Daytime Telephone: 

Daytime E-Mail Address:                  Cell Phone: 

Father's/Guardian's Name:    Daytime Telephone: 

Daytime E-Mail Address:                  Cell Phone: 

Emergency Contact Information:  In case of an emergency, Phillis Stewart Hall should contact

Name:     Telephone Number: 

Alternate Transportation Provider (complete if parents will not be transporting student):

Name:     Telephone Number: 

Name:     Telephone Number: 

Medical Information:

     Do you/does the student have any medical conditions which could affect your/his/her participation in class?  (Yes or No)

If YES, what is the condition, and what are its symptoms?

     Do you/does the student take any medicines which could affect your/his/her participation in class?  (Yes or No)

If YES, what is the medicine name, and what are its side effects? 

Medical Insurance Information:

Insurance Carrier:   Group/Policy Number: 

Registration Fee, Recital Fee and Tuition: 

  Please remember: you must pay the registration fee ($10.00 per student) and the session's tuition at the time of registration.

• Payment for Yoga is due every 6 weeks.  Tuition is $72.00 per 6-week session.

1st Tuition Payment: $ + Registration Fee (if not already paid): $10.00 = Total 1st Payment: $

Check # or Money Order # or Note if Cash Paid:   Make Checks Payable to PHILLIS STEWART HALL.

Release/Waiver and Payment Agreement:

     I acknowledge that I have enrolled myself in Vijaya Yoga with Phillis Stewart Hall, held at Leddy Center for the Performing Arts, and that I fully understand and appreciate that any activity which includes motion may cause accidental injury.  I have consulted my physician and received assurances from my physician that the physical activity required of the program for which I have enrolled does not pose a risk to me/my child.  I do not/my child does not have any medical condition/s which would be adversely affected by my/his/her participation in this program.  I understand that I have/my child has the right to participate only to the extent I/he/she am/is comfortable, and I/he/she will limit my/his/her conduct accordingly. 

     I accept responsibility for any injury, physical or emotional, which might arise out of this activity and agree to hold

Leddy Center for the Performing Arts, Inc. and Vijaya Yoga with Phillis Stewart Hall, harmless for any damages and/or costs, and will reimburse any legal fees, which may be incurred should I make demand or institute suit and be unsuccessful in any such action.  If I am unreachable, or I am/my child is unable to speak in the event of an injury, I grant permission for medical treatment to be given.

     I understand and acknowledge that I am responsible for paying for all lessons whether I/my child attend/s the lesson or not.  Furthermore, I fully understand when tuition payments are due, and will make payment on time or will be assessed a $10.00 late fee per week that payment is late.  I also understand that should I fail to make payment within one week of the due date, I/my child will not be allowed into class until payment has been made in full, including late fee.  Should this happen more than once, I understand that Leddy Center retains the right to re-assess the situation and take additional steps to protect its teachers, who rely on tuition payments for their income.  There are NO REFUNDS - NO EXCHANGES.

     I agree to allow Vijaya Yoga with Phillis Stewart Hall to use my likeness, either in still or moving form, for publicity purposes including, but not limited to, newspaper, internet, posters and TV advertisements.  I hold no contract with another agency or person which would prohibit such usage.

Please print this form, then sign and date.  Registrations are not accepted without signature and date.

Adult Student's or Parent/Guardian's Signature: _____________________________________________   Date: