Student Registration Form



Phone___________________________ Email____________________________________________

Emergency Contact _________________________________Phone__________________________

How did you hear about Trillium? _____________________________________________________


I, _________________________________ (print name), understand that yoga includes physical movements as well as an opportunity for relaxation, stress reduction, and relief of muscular tension. By choosing to participate in any class, workshop, or event, I voluntarily assume the risk of any injury to myself.

As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I understand that it is my responsibility to listen to sensations in my body. If I experience pain or strain, it is my responsibility to adjust or stop the yoga pose, and ask for support from the teacher. I may rest or ask for assistance at any time during the class or workshop.

I understand that yoga is not a substitute for medical attention, examination, diagnosis, or treatment. Yoga is not recommended and is not safe with certain medical conditions and acute injuries. I understand that I should consult my primary health care provider, doctor, nurse practitioner, physician assistant, or nurse midwife, prior to beginning any physical activity program, including yoga. I recognize that it is my responsibility to notify my teacher of pregnancy or any serious illness or injury before every yoga class. I affirm that I alone am responsible to decide to practice yoga.

By signing this form, I hereby agree to irrevocably release and waive any claims that I have now, or hereafter may have, against Trillium Integrative Community Wellness Center, Inc, or any teacher, officer, manager, or person affiliated with Trillium Integrative Community Wellness Center, Inc, for any damages I may sustain as a result of participating in its programs.

By signing below, I indicate that I have read the above disclosure and release information, all my questions have been answered, and I fully understand its contents. I voluntarily agree to the stated terms and conditions.

Yoga students under 18 years of age must have this form signed by a parent or guardian.

Parent/guardian signature____________________________________Date________________________