The Yoga Bungalow Consent

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The Yoga Bungalow Consent - Prenatal

Name *

Date Of Birth *

YYYY

Those under 18 years of age must also complete the youth consent form.

Address *

City *

Email *

Phone *

Emergency Contact Name *

Emergency Contact Number *

Due Date? *

YYYY

Have You Had Any Complications During Your Pregnancy? *

Is Your Midwife Aware You Will Be Partaking In Prenatal Yoga? *

Yes

If Yes, Has Your Midwife Recommended Any Precautions That We Should Be Aware Of?

Have You Practiced Yoga Before *

Yes

Limitations/Injuries *

Do You Have Any Pain In The Following *

None

Neck

Shoulders

Elbows

Wrists

Hands

Upper Back

Lower Back

Hips

Knees

Feet

Other:

Required

Is There Anything The Instructor Should Know About Your Pregnancy Or Health Background? *

Liability Release

If at any time during the class, you feel discomfort or strain, gently come out of the posture. You may rest
at any time during the class. It is important in yoga that you listen to your body, and respect its limits on
any given day. My Midwife is aware that I am participating in Prenatal Yoga.
I, the undersigned, understand that yoga is not a substitute for medical attention, examination, diagnosis, or
treatment. I should consult a physician prior to beginning any activity program, including yoga.
I recognise that it is my responsibility to notify my teacher of any serious illness or injury before every yoga class. I will
not perform any postures to the extent of strain or pain.
I accept that neither the instructor, nor the hosting facility, is liable for any injury, or damages, to person or
property, resulting from the taking of the class.
I accept that there are cameras for personal and property security.

I Agree To The Above Terms *

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This form was created inside of The Yoga Bungalow.