Student Information and Liability Form

Please know that your information is used for internal Uplift Yourself purposes ONLY and kept confidential.

If you are a parent/legal guardian filling out this form for someone under 18 years of age, please fill out the form with their name and information. Add your name with your signature below.

First Name*

Middle Name

Last Name*

Birthday*

Gender

Email*

Cell Phone*

Contact Preference?

Address*

City*

Country*

State*

Zip*

Password (Uplift Yourself Account Set Up)*

Confirm Password*

Receive Email Reminders?

Receive Email Newsletter (1-2 times a month)?

How did you hear about us?

Have you had previous experience with Yuan Gong or Ren Xue?

YES

If 'Yes'. Please list the practices, and for how long?

Have you been referred to a particular teacher?

YES

If referred, please list the teacher's name

Connectivity Preference for Session? (i.e. Zoom)

Do you have any health conditions or physical limitations that would be helpful for us to know?*

YES - Please describe health conditions below

Health Conditions:*

Emergency Contact Information*

Name*

Relationship*

Email*

Cell Phone*

LIABILITY RELEASE AGREEMENT:*

Nothing in Yuan Gong and Ren Xue is intended to take the place of your own regular medical care or as a substitute for medical care. If you have concerns, please consult your doctor before participation.

Please go at your own pace throughout the classes. If at any time you need to stop, sit down, lie down, get water, leave the class, etc. please do so and let an instructor know if you need any additional assistance.

Except in the case of gross negligence or malpractice, you or your representative(s) agree to full release and to hold harmless Ren Xue Center for Whole Life / Uplift Yourself from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with your classes and session(s).

By checking the box and signing below, you understand and agree to the above statements.

I understand and fully agree*

Signature*

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Clear

First and last name of the undersigner:*

The undersigner is*

seeking service for him/herself

is a parent/legal guardian of someone seeking service

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Student Information and Liability Form