REACH Yoga New Student Questionnaire
We have copies of the form available at Karma for you to fill out before your first class.
Email address *
Name *
Your answer
Address *
Your answer
Phone *
Your answer
In an Emergency, please call: *
Your answer
Date of Diagnosis
Your answer
Doctor/Surgeon Approval to practice Yoga *
Currently in Treatment? *
If Yes, please describe current status:
Your answer
Treatment
Treatment Type
Additional Treatments
Known Restrictions (Lymphedema, Infections, Scarring)
Your answer
Other Concerns
Do you currently have pain in any of the following?
Do you have any other previous injuries, health conditions, or surgeries? *
Student Liability Waiver Agreement
I understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor and I will continue to breathe smoothly. I assume full responsibility for any and all damages that may incur through participation.

Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. By signing, I affirm that a licensed physician has verified that my health and physical condition are sound enough to participate in such a fitness program. In addition, I will make the instructor aware of any medical conditions or physical limitations before class. I also affirm that I alone am responsible to decide whether to practice yoga and that participation is at my own risk. I hereby agree to irrevocably release and waive any claims that may arise against Reach Yoga.

I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. I am signing this agreement voluntarily and recognize that my signature serves as complete and unconditional release of all liability to the greatest extent allowed by law in the State of Michigan. *
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This form was created inside of Yoga By Design Foundation.