New Client Intake Form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Please review and acknowledge below. *

RELEASE & WAIVER OF LIABILITY I agree to the following: 1. The information I have provided above is complete and accurate. 2. I understand that I am participating in yoga conditioning, meditation, and holistic health/nutrition coaching sessions offered by Fern Langham. I recognize that yoga requires physical exertion that can be strenuous. I am fully aware of the risks involved. 3. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in yoga or nutrition changes. I represent and warrant that I am physically fit and have no medical conditions that would prevent me from participation in yoga sessions. I assume full responsibility for any injuries or damages, known or unknown, which I might incur as a result of participating in yoga conditioning sessions. I knowingly, voluntarily, and expressly, waive any claim I may have against Fern Langham for injury or damages that I may sustain as a result of participating in the program. 4. I understand that in the event that I need to cancel or change a scheduled session, I must do so at least 48 hours in advance, otherwise I will be charged the full amount of the session.

I agree