STILLPOINT: NEW  STUDENT FORM

PLEASE TAKE A MOMENT TO COMPLETELY FILL OUT THIS FORM - Thank you!

(Please Read!)  Release of Liability: In signing below I agree that Stillpoint Studios, Inc.  is in no way responsible for the safekeeping of my personal belongings while I attend class.  I understand that classes at Stillpoint Studios, Inc. may be physically strenuous and I voluntarily participate in them with full knowledge that there is risk of personal injury, property loss or death.  I agree that neither I, my heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against Stillpoint Studios or its members for any personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise.

Required:  Release of Liability - Signature

______________________________

NAME & ADDRESS                      (PLEASE PRINT LEGIBLY!)

Last Name      ___________________ First Name    ___________________

Address           ________________________ ________________________

City                  ________________________ State:____ Zip  ____________

 

PHONE #’s

Work Ph.         (____)___________  Ext._____Hm. Phone   (____)___________

Cell/Pager       (____)______________ Cell     (____)______________

 

OTHER INFO

Birth date       _____/_____/______

 

 

Email address  _______________________________  

EMERGENCY CONTACT

Name  ___________________ Relationship ______________

Phone # (____)______________