Name: _________________________________

Address: _______________________________________________________

Phone: Daytime: _____________________ Evening: __________________

Email: __________________________________________________________

Statement of Informed Consent

In participating in yoga classes conducted at Shanthi Mandir, Columbia, MO, I recognize that certain risks and dangers exist. These risks include personal injury and the loss or damage to personal property that may occur during my participation. I am aware that participation in this activity may include group exercises with members of the opposite sex. I am also aware that there are specific guidelines and rules regarding this interaction.

I understand that the instructor(s), Hindu Temple and Community Center (HTCC), their officers, employees and agents, volunteers, and all participants (hereafter “releases”) shall assume no responsibility or liability for me for accident, illness, or loss or damage of personal property. I acknowledge and do hereby assume all risks inherent in connection with this activity, and I for myself, heirs, executors, administrators and assigns do hereby expressly release and discharge the releases from all claims, demands, liability actions or judgments of any kind weather caused by the negligence of said releases or otherwise which I now have or in the future against said releases or any of them arising out of my participation in this activity.

My signature on this document certifies that my participation in the stated activities is voluntary and that I understand the risks involved in participation.

Signature: ________________________________ Date: ________________

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