Class & Workshop Registration Form

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( Face Ball CertificationBall Face Treatment Hands-On Table Recertification 3 Recertification day3 Note: , Intensive, repeats, or any training taken with Yamuna trainingwithrepeats,Intensive, taken any , or Yamuna® YogaYamuna® IsabelEisen (BL) Week 1 (BL)1 Week Course TitleCourse at time of registrationtimeofat 333 Hudson St., Suite 505 Hudson 333 St., Trainings Trainings (Phase (Phase & 2B)2APhase e (Phase 1& 2)Phase (Phase should be made payable to: Yamuna to: Yamuna Studio should payable made be www.yamunabodyrolling.com YAMUNA abroad and , , training 333 Hudson St., Suite 505, New York NY York 10013 Suite St., NY 505, New Hudson 333 a – 8 Week registration confirmation email confirmation responseregistration 212–

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Foot Fitness 1 Certification (Milan)Foot Part YBR

YBR ® BreathWorkCertification Experiential 1 Anatomy/Phase ® ® Body Body Logic Face Ball Certification Face Ball Hands-On Table Hands-On Treatment Recertification Recertification 3 day (Phase 1 & (PhasePhase 2) 1 Phase2 Foot Fitness PartFoot 2 Fitness PartFoot 1 Fitness YZStudio, Class & Workshop for are you registering Class & YBR Yamuna® YogaYamuna®

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Please print your name: print your Please Signature: Policies. Refund/Cancellation the as well as fullyits understand of andcontents waiverliability release and thehave read above I 7 Yamuna to and not sue discharge,covenant waive, release, representatives orforeseer legal my heirs I, 6) programs or classes, training permittedtoYBR® in of participatethebeing consideration further In 5) I ifequipmentto andandbe facilities used the right inspectmats, have duty that the to understandand I I 4) to I assume workshops,agree or classes beingparticipatefor training YBR®permitted to in consideration In 3) and in prior my participation to regarding a with to physician that consult understandmy responsibility it is I 2) WorkshopsYBR® or classes training Practitioner YBR® I participating am in That1) I, ) I

understand that until I complete allthe completethat YBR of understanduntil I teach or use the work with myclients.thewith workuse teach or acts. other their negligence caused byor death injury or employees any for or officers, Inc. instructors its Studio, program. in the participating a of asmaysustainresult that or I damages employees injury for instructors or officers, its Inc., and knowingly, voluntarily I workshops, torefuse andparticipate. condition(s) of such supervisor or instructor immediately I theadvise will beyond my capability or unsafe is that believe anything program. in the participating a of asresult I incur unknown whichmightknownor damages, or injuries risks, any for responsibility full participation prevent my full wouldwhichcondition medical nofit I that andhave warrantI physically andam I workshops.represent or classes trainingYBR® the involved. the hazards aware risks and of I fully and am injury, physical maycause and maybe whichstrenuous exertion andphysical requires contact physical involves program this recognize thatfitness instruction . I YBR® andabout information will receive during I which Inc. Please read, sign and return this waiver along with your registration form and health and questionnaire. health form with registration your this along read, return waiver sign and Please

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I voluntarily agree to the terms and conditions stated above.the conditions agree andtoterms voluntarily I ______(Please print your name)print your (Please , New York, NY 10013 NY New , 212. Tel: · York,

Continue to next Continue to page expressly waive any claim I may have against Yamuna Yamuna Studio, against I may have claim waive any expressly ® education

requirements @yamunabodyrolling.com Date: , hereby agree tofollowing hereby , the agree I am not a certified practitioner andnot a practitioner will I certified not am

367 ______. 9570 · Fax 212. ·

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April 2014 April

Thank you! Thank Body learnabout didyou Rolling? Yamuna® How /certificate license: offenses? traffic 212.367.9570 education at or Isabel Eisen classes our certification please contact with classes to entering prior any difficulty taking have those classes.of you If documentation Note: ink. inprint of sheet a separate On of Applicationenrollment date orlist date of ever you applied YBRHave to or attended previously? classes If “Yes,” please describe. please If “Yes,” ever you been ofHave afelonyminor other convicted than or misdemeanor, 4. Please describe any previous hands on experience that might have. on hands experienceprevious you describe any 4. Please one. have clientele, if you existing describe general your in 3. Please Rolling? Body learnchoosing Yamuna® for to reasons your are 2. What professional. health studenta future as weaknessesand a your and as strengths 1. Assess oaiis yu ae criid / lcne n ad te dt o eevd your received you date the and in licensed / certified are you Modalities it is a requirement that you experience classes from a Certified YBR® practitioner before you enter the program. Please submitprogram.the enter Please before you practitioner classesa Certified YBR® requirementfrom is experience it you that a YZStudio, the the 333 Hudson St., Suite 505 Hudson 333 St., paper, please answer the following questions, limiting your answers limiting answers following the questions, your please answer paper, www.yamunabodyrolling.com @yamunabodyrolling.com No , New York, NY 10013 NY New , 212. Tel: · York,

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