New Client Intake Form

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Name of Legal Guardian, if applicable *

First

Last

I understand the sessions are not an equivalent to counseling or behavioral health sessions, or to replace psychological care. *

Yes, I understand.

Payment & Appointment Information

Credit Card Number *

CVV *

Expiration (MM/YY) *

Zip Code *

Session cost is charged at time of making your reservation. 24 hour notice required to reschedule your session time (refunds not permitted).

Selection for Session Date/Time *

Session Length *

45 Mins ($70) 60 Mins ($85)

I give Latitude 44 Yoga Studio permission to charge my credit card the session fee rate + 5% to reserve my non-refundable appointment time. *

Yes, please schedule my appointment.

Waiver: I recognize that there are certain inherent risks associated with the activity as well as being in a public space. I assume full responsibility for personal injury to myself, potential illness, and further release and discharge Latitude 44 Yoga Studio LLC for injury or damage arising from the activity or from being in close contact with other people. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself and/or my children (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I and/or my child(ren) may experience or incur in connection with our attendance at the Studio. On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the Studio, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Latitude 44 Yoga Studio, its employees, agents, and representatives. I agree to indemnify and defend Latitude 44 Yoga Studio LLC against all claims, causes of action, damages, judgments, costs or expenses, including attorney fees and other litigation costs. I agree to pay for all damages to the facilities caused by my negligent, reckless, or willful actions. I agree and acknowledge that I am under no pressure or duress to sign this Agreement and that I have been given reasonable opportunity to review it before signing. I further agree and acknowledge that Latitude 44 Yoga Studio LLC has offered to refund any fees I have paid to use its facilities if I choose not to sign this Agreement. I agree to a photography release wherein Latitude 44 Yoga Studio LLC can capture live and still images and share them by means of social media, live streaming, and marketing. I understand if the class is booked at capacity, pre-registered spaces we will be given away 5 minutes prior to class. I should arrive to class 15 minutes early to reserve my space. I understand that there are no refunds or transfers available for any class, event, workshop, or membership purchases. _________________________ If partaking in the optional Reiki services, I understand that the topics discussed in these sessions are for entertainment purposes only. You are responsible for your own care as an individual and understand that Latitude 44 Yoga Studio LLC is not responsible for your care. [Electronic Signature] *

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