Register Online

Item:

Amount:
+ 13% HST

Registrant Information
First Name:	Last Name:
Date Of Birth:	Age: *Parent/Guardian Required
Parent/Guardian (required):
Alternate Parent/Guardian:
Address:
Address - Line 2 (optional):
City:	Province:
Country:	Postal Code:
Best Phone: () -	Cell Phone: () -
Home Phone: () -	Work Phone: () - ext.
Email:	Alternate Email:

Emergency / Medical Information

Emergency Contact Name:

Relationship:

Phone:

Doctor's Name:

Address:

Phone:

Please detail any physical aches, pains, or injuries:

If you are currently under the care of a doctor, please provide details:

Have you suffered from any of the following? (check all that apply):

Waiver

I agree to register the person named above for the program being offered by Centre for Well Being. I agree to release the instructors/owner and any associates with Centre for Well Being should any injury occur on or outside the premise while participating in programs being offered not limited to those of yoga, meridian stretch and strength, self defense and other. I agree to pay for the program in full and understand there is no refund for any reason. In the case of personal injury I agrees to indemnify and hold harmless Centre for Well Being and instructors from all losses caused by the accident or injury to the undersigned and/or registrant in the event that the undersigned and/or registrant is injured in any way during the performance and execution of the exercises. I acknowledge that it is recommended to seek the advice of a medical professional before starting any new physical program.

By clicking, I agree to this waiver.