Prasanthi Family Yoga & Wellness Center

www.prasanthistudio.com prasanthistudio@gmail.com
136 Fifth Avenue Pelham, NY 10803
914.380.4668

YOGA BIRTHDAY PARTY & YOUTH PROGRAM
WAIVER FORM

Students Name: ______________________________________________________________
Age____ Birthdate ___________ Grade ______ School_______________________________
Parents Name: _______________________________________________________________
Address: ____________________________________________________________________
Cell Phone: _________________________ Home Phone: _____________________________
Email _______________________________________________________________________
Emergency Contact (If parent is not available) ____________________ Phone ________________
Medical Information and/ or food allergies in relation to physical activity/ program participation


PLEASE READ CAREFULLY AND SIGN BELOW
Release Statement and Waiver of Liability: in consideration of the benets of instruction provided by
Prasanthi Studio, LLC, instructors, and the facility in which classes are held, I do hereby allow my child to
participate in yoga classes and do hereby waive claim and release Prasanthi Studio and its instructors for
claim or liability for any injury or accident occurring on or arising from my childs participation in the
instruction. I authorize emergency rst aid care to said student in the event he/she becomes injured or ill
during the instruction. If the parents and/or guardian of the child are not immediately available at the
telephone numbers provided above, I further authorize Prasanthi Studio, LLC to retain the services of a
physician or other emergency medical persons to treat the child and I accept full nancial responsibility
for any charges arising from such treatment.

____________________________________ __________________
Signature Student/ Parent/ Guardian Date