MS Yoga Sign Up Form – Academy of the Sacred Heart

Parent Name*

First Last

Email*

Phone*

Address*

Street Address City State ZIP Code

Payment for:*

$125.00 per child

Child's Name*

First Last

Child's Grade Level*

If your child has any health concerns, please specify below.

Child #2's Name*

First Last

Child #2's Grade Level*

If your child has any health concerns, please specify below.

Child #3's Name*

First Last

Child #3's Grade Level*

If your child has any health concerns, please specify below.

Is Late Dismissal Required?*

Total

$0.00

Please check to signify that you accept the following:*

I individually and as parent and/or guardian of the minor child identified above hereby acknowledge the following notices and grant to Bridget Maroney and the Academy of the Sacred Heart the following release from liability:
I acknowledge and fully understand that I, or my child, will be engaging in physical activities that may involve some risk of injury. I acknowledge and have been advised that it is my responsibility to consult with my or my child’s physician with respect to any past or present injury, illness, health problem or any other condition or medication that may affect my or my child’s participation. I assume the foregoing risks and accept full personal responsibility for any personal injuries sustained by my child which might incur as a result or participating in this program and discharge and hold harmless Bridget Maroney and the Academy of the Sacred Heart form any claim, cause of action or liability for damages arising from any personal injury to my child or other persons or property caused by myself or my child’s participation in the Yoga program.