First name

Last name

Email

Phone

Address

Emergency Contact Name

Emergency Contact Tel. No

Have you attended a yoga class before?

Yes

No

If yes, how long have you practised yoga and what style of yoga have you practised?

The following information is required to ensure your safety. Whilst yoga, Breathwork & meditation may be practised safely by most people, there are certain conditions that 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. If you attending a Breathwork or massage session you may be required to complete a separate form in addition to this.

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?

How regularly do you do this?

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, whether face to face or remote, and. 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

Remain on screen when participating in a remote yoga session I understand that for any periods of time throughout a remote session during which I move off screen or are outside of the teacher’s view, whether intentionally or not; no liability will arise on the part of the teacher.

I confirm I am over the age of 18 and am making this agreement of my own free will. I understand that if I am under age of 18 my parent or person with parental responsibilty will have to complete a separate consent form.

In order to comply with GDPR, it is necessary to check wether or not you are happy for us to retain your contact details, and to email you information we think will be useful to you, including, workshop, events, trainings and, relevant updates. I only ho

Text/WhatsApp

Email

Post

None

Please fill out this health questionnaire

DECLARATION