Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Seclect Accommodations *

Private Room w/Bath - $515.00

Shared Double w/Bath - $298.00 (Roommate must register separately and be listed below.)

Dorm Style w/Bath (4 per room) - $190.00 (Please list desired roommate(s) below if applicable.)

Dorm Style w/Bath (6 per room) - $155.00 (Please list desired roommate(s) below if applicable.)

Roommate 1

First Name

Last Name

Roommate 2

First Name

Last Name

Roommate 3

First Name

Last Name

Roommate 4

First Name

Last Name

Roommate 5

First Name

Last Name

Name on Card

First Name

Last Name

Expiration Date *

MM

DD

YYYY

I acknowledge that it is my duty to exercise ordinary care for the protection of others and myself while attending IOY/OBX and that the potential for accidents does exist. In consideration of acceptance to IOY/OBX: *

I imdemnify and hold harmless InsideOut Yoga LLC, Susan Johnson and MJ Anderson from any and all liability, claims, damage, injury or illness sustained by me and

I grant permission for InsideOut Yoga LLC, Susan Johnson or MJ Anderson to provide or obtain medical attention for me in the event of sickness or injury, and I understand that accident insurance is not included in the registration fee.

I agree that InsideOut Yoga LLC may photograph and/or videotape the activities for use in promotional materials.