LaughingRx          Registration / Payment

Class Registration form and waiver form:

Please copy and paste form below to email-   email to: Nira@LaughingRx.com

 Class name:  ________________________   Class location:  ____________________

Class time:__________________                    Class date:  _______________________

Signing up for one class____      series of classes  ________  

Registrant Name(s):_____________________________________________________

telephone number:  (daytime)_________________   (evening)                          _____.

address:_______________________________________________________________

_______________________________________________________________________

email:  _________________________________________________________________

emergency contact:  name: ________________________________________________

telephone: ______________________________________________________________

How did you hear about class?   friend____ newspaper____ TV_____ email_______

referral name:_________________________________________________________

Have you previously experienced LaughingRx?____________________________

Experienced Laughter yoga elsewhere?____ where?________________________

What is your most important goal you'd like to achieve by participating in LaughingRx:

check all that apply:

stress reduction____  lower blood pressure_____   boost immune system_____

Positive experience_____  fun_____   mental clarity___________  greater energy_____

  

Payment:  Cash_________   Check____________  #___________

credit card # ___________________________________ circle: Visa   MC   AmEx   exp date_________

name on card:____________________________________________________

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Form below needs to be printed, filled out, signed and mailed or brought with to first class

Waiver

Name:  ______________________________________________________________________________

Address:  ___________________________________________________________________________

____________________________________________________________________________________

Telephone:  w:____________________   H:_____________________  cell:_______________________

 email:  _________________________________________________________________

emergency contact:  name: ______________________________tel:____________________________

I release LaughingRx and Nira Berry from any health issues or injuries as a result of participating in a LaughingRx workshop, class, presentation and/or any type of event.

I understand Laughter Yoga as in LaughingRx can induce heavy laughter and heavy breathing. All participants with heart ailments or asthma should check with their doctor first for clearance to participate.

Signature_________________________________________  date:  _______________________

Print Name_____________________________________________

Thank you,

LaughingRx, LLC