Name *

First Name

Last Name

Phone *

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

Waiver *

I recognize that risk of injury or potential health risk may be involved in participation in the above-named programs/activities. I hereby will- ingly assume such risk of injury or health risk for myself and my participation in the programs/activities. In consideration of the acceptance of my application and permission to participate in the programs/activities, I for myself, my heirs, executors, administrators, successors and assigns, HEREBY RELEASE, WAIVE, WAIVE AND FOREVER DISCHARGE 5 Elements Yoga & Pilates Inc., all other organizations, as- sociations and companies associated with any of the programs offered by 5 Elements Yoga & Pilates Inc., and all their respective agents, employees, officials, servants, contractors, representatives, elected and appointed officials, successors and assigns OF AND FROM ALL claims, demands, damage costs and actions whatsoever and however caused, arising to or to arise by reason of my participation in the program or any of its associated activities.