Cart 0

Tui Na/Qi Gong/Tai Chi

Class Registration Form

Name

First Name

Last Name

Date of Birth

YYYY

Gender

Male

Female

Cell Phone

(###)

###

####

Address

Occupation

Referred By

Emergency Contact (Name, Phone #, Relation)

Reason(s) to join class/Expectations

Disclaimer

PLEASE READ THE SECTION BELOW AND SIGN: I recognize and acknowledge that there are certain risks of physical injury to participants in these classes, and I voluntarily agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that I may sustain as a result of said participation. I further agree to waive and relinquish all claims I may have (or which accrue to me) against Wu Healing Center, including its agents, volunteers and instructors as a result of participating in these classes. I do hereby fully release and forever discharge Wu Healing Center from any and all claims for injuries, damages or loss I may have or which may accrue to me and arising out of, connected with or in any way associated with these classes. I have read and fully understand the above waiver and release of all claims. If I am registering online or via fax, my online or facsimile signature shall substitute for and have the same legal effect as an original form signature.

Patient Signature (or legal guardian if patient is a minor)

Date

Signature