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Name Username* First Name* Last Name* Nickname I allow the website to collect and store the data I submit through this form.*Contact Information Home Phone Required phone number format: (###) ###-#### Cell Phone Required phone number format: (###) ###-#### E-mail* Country* Select a CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the CongoReunionRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe Address* City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMinor Outlying IslandsMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasU.S. Virgin IslandsUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Province/Territory Please list any personal injuries or restrictions. Please let your teacher know before class: How did you discover Synergize? (internet, Facebook, friend, etc.) Emergency Contact Information Contact Name Contact Phone Number I give you permission to contact this person in the event of an emergency.I consentTerms and ConditionsI am aware that SYNERGIZE INC. is here to serve me by sharing knowledge of Yoga and health. I understand that the practice of Yoga and exercise involves physical movement, which may from time to time be strenuous, and that such practice carries some risk of injury. I also understand that I must judge my own capacities with respect to practicing yoga and exercises during any classes offered through SYNERGIZE INC. I acknowledge that it is my responsibility to inform the instructor when I begin a class of any injury or other condition that might affect my ability to participate, and to inform the instructor immediately if any injury incurs during class. I understand that from time to time during classes through SYNERGIZE INC., the instructor may give hands-on assistance to facilitate the understanding of postural alignment. If I do not want such assistance, I will inform the instructor at each class I attend. I hereby agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the classes and/or workshops of yoga, exercise, and/ or meditation offered through SYNERGIZE INC. I voluntarily waive any claim I may have against any person or entity in any way involved therewith, including without limitations, its principal, instructors, independent contractors, employees, agents and representatives and their successors and assigns.I have carefully read the release, fully understand and agree to the above. Signature of participant* Date* Check this box if the participant is under 18 years of age.I am under 18 years old.As legal guardian of the above named person, I consent to all of the terms above. Date Signature of Parent/Guardian Optional Biographical Information About Yourself Website Enter Your Password Password* Minimum length of 8 characters. The password must have a minimum strength of Medium.Strength indicator Your SubscriptionsSelect subscription plan1 Session Class Pass - 30 Days - $18 / 30 DaysALL Live Yoga, Meditation, and Pranayama Classes and Free Membership Events and Recordings. Walk-in session must be used with in 30 day. 30 day Expiration from purchase date. Includes most yoga events - See Event for more details. May Exclude Some Special Events - See Event for details. Excludes Program, Courses, On Demand Classes. 30 Day Unlimited Live Yoga Class Pass - $99 / 30 DaysALL Live Yoga, Meditation, and Pranayama Classes and Free Membership Events and Recordings. 30-day Expiration from purchase date. Includes most yoga events - See Event for more details. May Exclude Some Special Events - See Event for details. Excludes Program, Courses, On-Demand Classes. 30 Day Unlimited Live Yoga Classes + On-demand - $129 / 30 DaysALL Live Yoga, Meditation, and Pranayama Classes and Free Membership Events and Recordings. 30-day Expiration from purchase date. Includes most yoga events - See Event for more details. Includes On-Demand Classes - See On-demand for details May Exclude Some Special Events - See Event for details. Excludes Program and Courses 30 Days of Ayurveda FREE - Transform Your Life One Small Step at a Time - Free / 30 DaysWeek #1 Clockwork + Meditation Week #2 Senses + Pranayama Week #3 Move your body + Yoga Week #4 Happy Belly + Recipies 30 Days of Ayurveda Group - Transform Your Life One Small Step at a Time - $79 / 30 DaysWeek #1 Clockwork + Meditation Week #2 Senses + Pranayama Week #3 Move your body + Yoga Week #4 Happy Belly + Recipies weekly group check-ins - more information coming soon 30 Days of Ayurveda Private with Kamie - Transform Your Life One Small Step at a Time - $175 / 30 DaysWeek #1 Clockwork + Meditation Week #2 Senses + Pranayama Week #3 Move your body + Yoga Week #4 Happy Belly + Recipies A Private Session + weekly check-ins - More Information to Come! 4 Session Class Pass - 30 Days - $56 / 30 DaysALL Live Yoga, Meditation, and Pranayama Classes and Free Membership Events and Recordings. 4 sessions must be used with in 30 day. 30 day Expiration from purchase date. Includes most yoga events - See Event for more details. May Exclude Some Special Events - See Event for details. Excludes Program, Courses, On Demand Classes. 6 Session Class Pass - 30 Days - $72 / 30 DaysALL Live Yoga, Meditation, and Pranayama Classes and Free Membership Events and Recordings. 6 sessions must be used with in 30 day. 30 day Expiration from purchase date. Includes most yoga events - See Event for more details. May Exclude Some Special Events - See Event for details. Excludes Program, Courses, On Demand Classes. Ayurveda Private Program Plus - $349 / 30 Days30 Days of All access 1 Private Ayurveda Session (1.5) per month or 1 hour session with one 30 min check in. All Live and On Demand (Recorded) Classes - Yoga, Meditation, Pranayama Cooking Classes - Recorded MORE TO COME.... FREE: When Shift Happens Membership - FreeA membership that allows access to free content available only to basic subscribers. This membership is our way of saying "thank you" for subscribing and following our content.GrandYogi Package - $100 / 30 DaysGrandYogi package for Long time students and COVID Loyalty. Discounts are sent to student that fall in this category. Monthly On Demand - $49 / 30 DaysOn Demand Only Teachers ONLY - 30 Days on demand Stress Management and Self Care - Free / 30 DaysYoga, meditation, mindfulness, nutrition, journaling, community, and more! More Info Comming soon! Send these credentials via email.
