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Kids Yoga Intake Form
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First name (Child’s) *
Last name (Child’s) *
Date of Birth *
MM
/
DD
/
YYYY
Address *
City *
State *
Zip Code *
Cell phone *
Home phone *
Work Phone *
E-mail *
Emergency Contact (Name/Phone Number) *
Why are you interested in yoga for your child? *
Please describe your child's present health problems and their duration
Does your child have any chronic condition I should be aware of? *
If you answered 'yes' to the last question, please describe in more detail. *
Does your child take any medications, nonprescription medications, vitamins, or other supplements? If yes, please list here. *
Is your child currently under the care of a family physician or any other health professional. If yes, include details. *
Does your child have any past medical history or problems (trauma, anxiety, emotional distress) Please describe in detail here. *
Is there a family history of the health problems listed above?
Please check off any conditions listed below *
Required
Daily routine
This section has questions about your child' daily routine which may help decide the best time for yoga!
Does your child get up early? *
If early, what time? *
Time
:
Does your child go to bed early? *
If early, what time? *
Time
:
Does your child sleep during the day?
Clear selection
If yes, what time of day? *
Time
:
How does your child generally feel when they wake up in the morning?
Clear selection
How would you describe your child's experience of sleep? *
How regularly does your child follow their ideal routine? (ex: go to bed on time, eat meals on time) *
What day/time of the week would work best? *
How many sessions per week? (3 session max) *
Please sign the Client Information Form and Release below
Please sign using your first and last name. (Parent signature)
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. I will continue to breathe smoothly. I assume full responsibility for any and all damages, which 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 my good health and physical condition 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 participation is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Moon Breath Yoga and it's instructors.

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 Massachusetts.
 *
I agree that if my child seems to be acting in an inappropriate manner such as hitting, biting, kicking the instructor, I have tools to help calm down the child. In addition, if this occurs in 3 sessions, the instructor has the right to no longer have sessions with my child. Yoga is not a therapy intervention, rather a tool to help your child calm down. *
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