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Prenatal Yoga Registration & Disclaimer Form
Your information is kept confidential and used only for the purposes of understanding your needs as an individual and to reach you in the event of class changes or cancellations.
Yoga4U - The Yoga & Reiki Studio
Name *
Birthdate *
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DD
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Email *
Address *
Phone number *
Emergency Contact Name *
Emergency Contact Number *
OB/GYN or Other Health Care Professional: *
Phone Number (Health Care Info) *
Due Date: *
MM
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DD
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YYYY
How did you hear about us? *
Are you new to yoga? *
Have you practiced yoga since you’ve been pregnant? *
What are your main reasons for taking yoga classes?
Column 1
To increase flexibility
To improve muscle strength
To increase energy
To reduce muscle tension in neck, shoulders
To reduce muscle tension in lower back
To reduce feelings of stress/increase peace of mind
To improve breathing/learn new breathing techniques
To improve balance/coordination/stamina
Do you currently have any injuries or physical limitations in addition to pregnancy? Please describe. *
Please describe in detail any other health or medical condition that you believe may be helpful for your yoga teacher to know: *
Yoga Class Options:
Column 1
4 Classes/Month $68.00 (Group Class)
8 Classes/Month $120.00 (Group Class)
12 Classes/Month $160.00 (Group Class)
One on One Class $40.00/Class (Private)
Class Start Date *
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DD
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Payment: Cash/E-transfer *
Disclaimer:
I acknowledge that it is my duty to exercise ordinary care for the protection of others and myself while attending yoga class or other classes at Yoga4U. I assume the risk of physical activity with my own physical condition. I have received advice from my doctor that I am capable of physical exercise such as provided by Yoga4U, or I will seek such advice, or I will assume the risk of exercising without a doctor’s examination. This form continues to be effective as long as I am taking classes at Yoga4U or from its instructors in Yoga4U or other locations.
I take complete responsibility for my presence at the Yoga4U and I will not hold Gayatri Pathak or any other instructors or Yoga4U responsible for any injuries or loss I may incur as a result of my participation in any yoga classes or other classes and for any time I am taking classes.
I hereby confirm that I have read and fully understand this release of liability and assumption of risk agreement, fully understand its terms, and sign it freely and voluntarily without inducement.
Signature & Date: *
| Yoga4U |Gayatri Pathak|647-628-8241| gpathak13@yahoo.com | 13 Bonavista Drive, Brampton ON L6X 0N2|
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