Prenatal Yoga with Mariellen - Registration
Fill out this form to pre-register for prenatal yoga classes with Mariellen VanDyke Brown. Classes are held at Jillian's Drawers in the Ithaca Commons on Mondays from 5:30-6:30 p.m. and Wednesdays from 8:00 - 9:00 a.m.
Email address *
Name (First & Last) *
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Phone
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Address
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Emergency Contact Name *
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Emergency Contact Phone *
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Due Date *
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Dr/OBGYN Name *
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Do you have any general health issues? *
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Is this your first pregnancy?
What pregnancy symptoms are you currently experiencing? (nausea, acid reflux, sciatica, pain, etc.) *
Your answer
Have you taken yoga classes before?
If yes, where?
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How did you hear about this class? (check all that apply)
What are your goals for this class?
Your answer
Waiver & Release
By typing your name below, you agree to the following statements:

I understand that yoga includes physical movements as well as an opportunity for relaxation, stress reduction, 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, adjust the posture, and ask for support from the teacher.

Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I affirm that I alone am responsible to decide whether to practice yoga. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against the yoga instructor and the studio where I am practicing.

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Today's date
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Looking forward to seeing you at class! :)
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