Name
*
First Name
Last Name
Date of Birth
note that month is first, then day
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mobile Phone e.g. 44 779 864 3589
*
Country
(###)
###
####
Home Phone
Country
(###)
###
####
Email
*
Emergency contact name
*
First Name
Last Name
Emergency contact telephone number e.g. e.g. 44 779 864 3589
*
Country
(###)
###
####
Have you attended a yoga class before?
*
If yes, how long have you practiced yoga and what style of yoga have you practiced?
The following information is required to ensure your safety. Whilst yoga may be practised safely by most people, there are certain conditions which require special attention. If you are unsure, please consult your GP before commencing class. Please tick the boxes below if you have any of the following medical conditions.
*
These conditions require specific modifications to your yoga practice. If yes, please give details.
Further Information
These conditions may affect your practice and so provide useful information for your tutor.
*
Further Information:
Please tick this box if you do not wish to declare medical information
Have you had any recent operations (in the last two years)?
*
Do you have any old injuries that still trouble you? Or any other medical conditions not covered above that might be adversely affected by yoga practice?
Are you /could you be, pregnant, or have you given birth in the last six weeks?
Do you participate in any other physical activity, e.g. gym, jogging, swimming, aerobics, cycling, walking or other? If so, how regularly do you do this?
How did you hear about these classes?
DECLARATION
I confirm the above information is correct and that I take responsibility for my own health and safety whilst participating in the yoga class. I also understand that it is my responsibility to:
• check with my doctor if I have any difficulties or concerns about my ability to participate in the yoga class
• advise the yoga tutor of any change in my medical information or ability to participate in the yoga class
• follow the advice given by my doctor and/or yoga tutor
Name & Date
*
This acts as your digital signature when submitting the form
In order to comply with the General Data Protection Regulations, it is necessary to check whether, or not, you are happy for me to retain your contact details, and to email you information I think will be useful to you, including training and events, and relevant updates. I only hold information when it is necessary for me to carry out my work, and when you have given me permission to do so. To ensure that I only communicate with you in the manner of your preferred choice, can you please indicate below your preference(s) or otherwise, when contacting you. Please note that you are able to amend these choices at any time by contacting your tutor.
*
Preferred means of communication