Loker School After-School Yoga Registration Form
Grades K-2
7-Week Session: Tuesdays, April 11 – May 30, 2017
(no class April vacation week)
Student Name: Grade: Address:
Health needs/physical limitations______
Parent/Guardian Contact information:
Name: Phone:
Email:______
AGREEMENT TO POLICIES/LIABILITY WAIVER
I individually and as parent and/or guardian of the minor child identified above hereby acknowledge the following notices and grant to Amy Hrobak and Wayland Public Schools the following release from liability: A. I acknowledge and fully understand that I, or my child, will be engaging in physical activities that may involve some risk of injury. I acknowledge and have been advised that it is my responsibility to consult with my or my child’s physician with respect to any past or present injury, illness, health problem or any other condition or medication that may affect my or my child’s participation. I assume the foregoing risks and accept full personal responsibility for any personal injuries sustained by my child which might incur as a result or participating in this program and discharge and hold harmless Amy Hrobak, Wayland Public Schools, its owners, directors, members, employees and agents from any claim, cause of action or liability for damages arising from any personal injury to my child or other persons or property caused by myself or my child’s participation in the Loker School After-School Yoga program.
______
Signature of Parent/Guardian Date
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Parent name (printed)
*Cost: $84 for the seven-week session. Please make checks payable to WSCP (Wayland School Community Programs). Turn in check and registration form to WSCP office at Loker School. *Limited space is available. Amy will be contacting parents prior to the first session to confirm child’s participation.
Media Permission Circle: I agree or I do not agree
My child(ren) may be photographed at Yoga for possible use in brochures, websites, print or online newspapers/newsletters.