Name *

First Name

Last Name

Phone *

Please provide the phone number and email address you most commonly use so I can reach you in the event of waitlists/class cancellations.

(###)

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Have you practiced yoga before?

Yes

No

Is there any reason why you should not participate in physical activity?

Yes

No

Do you suffer from any of the following?

Please tick all that apply

High Blood Pressure

Low Blood Pressure

Heart Issues

Back Issues

Eye Issues

Chest Complaints

Arthritis

Hernia

Migraine

Anxiety

Depression

Pelvic Girdle Pain

Diabetes

Incontinence

Pelvic Floor Issues

Hyperemesis Gravidarum

Swelling

Heartburn/Acid Reflux

Haemorrhoids

Wrist Pain/Carpal Tunnel Syndrome

Join Problem (Neck, back, shoulder, knee, other)

Prolapse

Class Waiver

Many people practice yoga for many years without incident. However, as with any physical activity, care and restraint must always be exercised by the individual. I accept and agree that the responsibility for ensuring that my individual limits are not exceeded rests with me and not with the teacher, and that no liability shall attach to the teacher in respect of any injury sustained by me during class or in the practice of yoga. If there is any doubt about my ability to participate in any aspect of yoga, I shall first seek independent professional advice. I also understand that the teacher may offer guidance and support for pregnancy and birth, however, this does no supersede my autonomy, decision making ability nor any medical advice I receive during pregnancy and birth.

I agree