8/11/2019 Ripina Yoga Membership Application Form

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Ripina Yoga Studio: http://www.ripinayoga.com.au

RIPINA YOGA MEMBERSHIP APPLICATION FORM

Personal Details

Date: ____ / ____ / ________

Full Name: ..………………………………….…...

Date Of Birth: ……………………………………. 

Email: …………………………………………….. 

Mobile/Phone: ……………......…………….…… 

Student  /Normal Member / Senior  

Memberships:

  10 passes  1 month  1 Year

 3 months   6 months

Preferred Time Slots (Please tick)

Mon Tue Wed Thu Fri Sat

6h457h45

09h3010h30

16h3018h00

18h3019h30

19h3020h30

 Allowing photographs: yes   no  

Your Health

Please read the following questions carefully

and answer each one honestly, deleting as

appropriate or adding information if necessary.

Responses are confidential. Have you ever

had any history of the following?

  Y/N Heart problems

  Y/N Pain in chest when exercising

  Y/N Low Blood pressure

  Y/N High Blood pressure  Y/N Any breathing difficulties or asthma

  Y/N Diabetes  Y/N Fainting spells

  Y/N Joint problems

  Y/N Back complaints

  Y/N Are you on any sort of medication?

  Y/N Other significant illness/operations?

If yes, please specify

..........................................................................

..........................................................................

(If you have answered yes to any of the above

questions you must consult your doctor prior to

exercise.)

Terms and Conditions of

Membership

Release and Indemnity

a) I agree to  r elease, waive, and discharge

Ripina Yoga, and each of their respective

owners, officers, directors, shareholders,

principals, agents, representatives, and

employees (the Indemnified) of all liabilities,

actions, claims, demands, costs, losses or

expenses which I, or any of my successors,

guardians, legal representatives or assigns,may have against either of the Indemnified, or

all of them, for any loss, damage, claim or

demand other than in relation to workers

compensation law, on account of injury,

property damage, or death, arising out of, or in

any way connected with, my attendance at,

and/or participation in, the Activity; and 

b) I agree to indemnify, save and hold

harmless each of Ripina Yoga from any loss,

liability, damage or costs incurred, including

but not limited to any third party claims, due to

8/11/2019 Ripina Yoga Membership Application Form

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Ripina Yoga Studio: http://www.ripinayoga.com.au

my attendance at, and participation in yoga

practice. 

c) I am in good health and do not suffer from

any mental or physical condition or disability,

or pre-existing impairment, illness or injury

which would give rise to the risk of injury by myattendance and participation in the Activity, or

which would impair my ability to understand

this Release and Indemnity. In the event that I

am ill or injured or suspected to be ill or injured

I consent to receiving medical treatment as by

medical professionals.

Fees

Membership is available to all Ripina Yoga

students, Staff and Fellows on an annual andmonthly basis. The fees are outlined in theprice list. And are subject to change by theyoga committee and is non-refundable (unlessexceptional circumstances arise).

General

You must observe all rules of use in ‘Ripina

Yoga Studio’.

Clean footwear must be worn. Please remove

your shoes prior entering the studio. Shoe

racks are provided at the entrance. 

Declaration

I have read the terms and conditions and

agree to abide by them. I have, to the best of

my knowledge, completed the health

questionnaire and informed employees of the

Ripina Yoga Studio of any relevant

information.

Signed: ……………………………………………