Dream Yoga Studio Paper Registration Form

If you do not wish to register on-line, you can fill out the form below and mail it in (or bring it to the Studio) with your check, money order or credit card information for the full amount due. You can also pay at the Studio via cash, check, money order or credit card.  Your payment will reserve your spot in the class(es) or workshop(s) you have selected. 

 

Mail or deliver to:

             DREAM YOGA STUDIO & Wellness Center

1485 Chain Bridge Rd, Suite 104

McLean, VA 22101

 

 

Name

 

Address/City/Zip

 

Home Phone

 

Work Phone

 

Mobile Phone

 

Email

 

Birth Date

 

Emergency Contact Name & Phone

 

 

How did you hear about us?  ___Friend   ­­­___Web   ___Ad   ___Saw Studio   Other:________________________________

Class or Workshop Title

Class Day & Time

1

 

2

 

3

 

4

 

 

Alternate Class

Class Day & Time

1

 

2

 

3

 

Health Issues

  

 

 

I am paying via     ___check/money order enclosed       ___credit card

If Credit Card:  ___Visa     or     ___MasterCard

 

Name on Card:

Amount to be Charged:

Is Address Same as Above?:    ___Yes   ___No

If no, please insert here:

 

 

Card Number: _________________________

 

Card Verification Code/Number:  ___________

(last 3 or 4 digits shown in signature area on back of card)

*Signature:

Expiration Date:

*Agreement

 My signature above affirms that I agree to allow Dream Yoga Studio to charge my account for the amount specified for the class(es) and/or workshop(s) I have selected.

 

 

REGISTRATION AGREEMENT

I understand that Yoga/Meditation is a physical discipline that requires a certain amount of mental concentration and physical strength and endurance. I agree to work at my own pace and according to my own limitations, and I take full responsibility for my safety and well-being. I hereby release Dream Yoga Studio, LLC,  its instructors,  and T&M McLean Ventures/Metro Management Services from any liability associated with my participation in any classes and/or private instruction provided.

        I also understand: Dream Yoga Studio is a member of a network of yoga studios affiliated with Kripalu Center for Yoga and Health, Stockbridge, Massachusetts.  This yoga studio, like all Kripalu affiliated yoga studios, is independently owned and operated.  Kripalu Center for Yoga and Health is neither responsible nor legally or financially liable for the activities conducted at this yoga studio.

        I also agree that I am solely responsible for the safekeeping of my personal belongings while I attend class.

Signature

 

Date