Name *

First Name

Last Name

Phone Number *

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Date of Birth *

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Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Number *

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Non-Refundable Deposit *

Yes, I understand a $750 deposit is required to secure my spot on this retreat and is non-refundable. Full payment due by December 16, 2020.

ASSUMPTION OF RISK, HEALTH WARRANTY, RELEASE, & WAIVER OF LIABILITY: *

YES: I understand and accept the terms of this contract.

Yoga is an individual experience and I understand that I should progress at my own pace while participating in the physically active portions of "Bali Yoga + Wellness Retreat" with Cooper Chou & Jessica Chin ("CC/JC"). If at any point I feel overexertion or fatigue, I will respect my own body’s limitations and I will rest before continuing Yoga or any other exercise. I acknowledge that participation in "Bali Yoga + Wellness Retreat" naturally involves the risk of injury to me. I further acknowledge that specific risks include injuries resulting from overexertion, physical adjustment, improper or negligent use of equipment, failure to follow teacher instructions, or injuries resulting from participation in an inappropriate level of physical exercise. As such, I understand and voluntarily accept these risks. I represent that I am in good health, at least 18 years of age, have the necessary current medical approval to engage in physical exercise and yoga instructional classes and have no disability, impairment, injury, disease or ailment which would cause risk of injury or adverse health consequences as a result of engaging in physical exercise and yoga instructional classes. I acknowledge that to the facility where I am participating in my retreat and Cooper Chou & Jessica Chin are relying on this representation and I understand that neither to the facility where I am having my retreat nor CC/JC will investigate or certify my health or my fitness to participate in physical exercise and yoga instructional classes. YES: I understand the

RELEASE AND WAIVER OF LIABILITY: *

YES: I understand and accept the terms of this contract.

In consideration for my participation in "Bali Yoga + Wellness Retreat" with Cooper Chou & Jessica Chin, I, individually, and on behalf of my relatives, legal representatives, and assigns, agree not to sue and hereby agree to defend, indemnify, release and hold harmless to the facility where I am doing my retreat and Cooper Chou & Jessica Chin ("CC/JC")and each of their respective shareholders, owners, officers, directors, members, employees, contractors and agents, and the owner of the BeingSattvaa (the “Facilities”) where the Retreat occurs (collectively, the “Releasees”) from all actions, claims, demands, suits, losses, liabilities, charges, expenses (including, without limitation, attorneys’ fees), and costs of any nature whatsoever which may arise out of, relate to, or result from, any injury, economic loss or any damage to me or my guest or relatives resulting from my participation in physical exercise and yoga instructional classes at the Facilities, entry to or use of the equipment, facilities or services at the Facilities, the negligence of to the facility where I am doing my retreat or Cooper Chou & Jessica Chin, anyone at to the facility where I am doing my retreat or Cooper Chou & Jessica Chin’s behalf or anyone using the Facilities or CC/JC’s equipment, facilities or services, except such as may arise out of the gross negligence or willful misconduct of the Releasees. This release and waiver of liability (this “Release”) is intended to be a complete release of any responsibility for personal injuries and/or property loss/damage sustained by me while at the Facilities, whether using exercise equipment, participating in active or passive exercise, or not. I understand that this Release is intended to be as broad and inclusive as it permitted by the laws and jurisdiction applicable to the facility where I am taking my training and that if any portion of this Release is held invalid, I agree that the balance of this Release should continue in full force and effect.