Name________________________________________________________

Address:______________________________________________________

City___________________State______________Zip__________________

Phone Number:_________________________________________________

Email:________________________________________________________

Birthdate______________________________________________________

Emergency Contact:_____________________________________________

Emergency Contact phone number:_________________________________

Please List Any Injuries, Pregnancy, Concerns:________________________

__________________________________________________________________________________________________________________________

       I_________________________________________________ release Sacred Waters, Samapati LLC, and its owners, employees, and agents and will hold them harmless from any and all Liability arising out of any personal injuries  or damages, foreseeable or unforeseeable, which may occur as a result of my participation in any class, program, session or activity sponsored by Sacred Waters or Samapati LLC.  I hereby declare myself physically and mentally sound and capable of participation in these activities, programs, and classes.

 Signature __________________________________________________________________Date:_________________