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
6h45
7h45

09h30
10h30

16h30
18h00

18h30
19h30

19h30
20h30


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 release, 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

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 my
attendance 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 and
monthly basis. The fees are outlined in the
price list. And are subject to change by the
yoga committee and is non-refundable (unless
exceptional 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: