Hello!

We’re looking forward to the Birth Preparation and Educational class. Please take a few minutes to complete the intake form and class registration/waiver.

Who Is attending?

Name 1

First Name

Last Name

Email 1

Name 2

First Name

Last Name

Email 2

What is the estimated due date?

YYYY

What are you most interested in learning about?

What would help you feel confident going into the birthing process?

Is there anything you would like Sylvia and Alicia to know about you in particular?

Please review the following information and sign at the bottom

Date(s): Friday, January 28th 5:30-8:30PM & Saturday, January 29th 12:30-6:30PM Location: Utah Prenatal Yoga in Brickyard Plaza Please arrive a few minutes early so that we can start right on time. We have so much to cover and would like to avoid disruptions with late arrivals. • Shoe-free facility (let your partner know in advance) • Masks required while we are inside together (because, safety) • Snacks/drinks welcome, please no full meals/smelly foods (out of respect for the pregnant sense of smell) *** Please bring a seating option if you know that floor seating/bolster/cushion will not work for you. A camping chair is highly recommended *** or whatever you would feel comfortable in for an extended period of time. We will be moving around between sections to help break it up for you! Cancellation/refund Policy: you can request a refund for your registration if you cancel prior to 1 week before the class. No refunds will be offered for cancellations inside of 1 week. If you decide you would rather join us online/virtual, please let us know as soon as possible.

I understand that the Birth Preparation and Education Class is offered as a community education resource and is not offered expressly by Utah Prenatal Yoga LLC. I understand that the Birth Preparation and Education Class is not presented as medical advice, treatment or diagnosis. All instruction, materials and interaction do not represent or replace medical advice.I hereby waive and release Sylvia Wagner and Alicia Poldino, or any person or entity involved therewith, from any claim that I may have at any time for injury of any kind to myself or any minors or individuals under 18 years of age that attend class or instruction with Sylvia Wagner and Alicia Poldino while in my care. I also understand that the activities that I will participate in may be considered inherently dangerous and may cause serious or grievous injuries, including bodily injury, COVID-19 infection, loss of/damage to personal property and/or death. On behalf of myself, my heirs, assigns and next of kin, I waive all related claims for damages, injuries and death sustained to me or my property that I may have against Sylvia Wagner and Alicia Poldino and Utah Prenatal Yoga LLC. I hereby waive and release any claim that I may have at any time for injury of any kind against Utah Prenatal Yoga, LLC or any person or entity involved therewith, including but not limited to its members, managers, instructors, employees, agents, representatives, locations or hosts. I hereby waive and release any claim that I may have at any time for injury of any kind to myself or any minors or individuals under 18 years of age that attend class or instruction with Utah Prenatal Yoga while in my care. I hereby consent and agree to grant all rights to photographs or videos taken of me, or of any minor accompanying me, during class or instruction to be used by Utah Prenatal Yoga, LLC for unrestricted personal or commercial use and reproduction. All equipment and services of Utah Prenatal Yoga are subject to change or deletion at the discretion of the Utah Prenatal Yoga, LLC. This release shall be binding upon me and my heirs, legal representatives, and assigns.

I have carefully read and understand the above Release of Liability and I agree to the above by signing below.

First Name

Last Name