Health Questionnaire
Declaration

I confirm the information below is correct and that I take responsibility for my own health and safety whilst participating in the yoga class. I also understand that it is my responsibility to:
• Check with my Doctor if I have any difficulties or concerns about my ability to participate in the yoga class
• Follow the advice given by my doctor and/or yoga teacher
• Advise the yoga teacher of any change in my medical information or ability to participate in the yoga class
• Remain on teacher’s screen when participating in a remote yoga session.

I understand that for any periods of time throughout a remote session, during which I move off-screen or are outside of the teacher’s view, whether intentionally or not; no liability will arise on the part of the teacher.

I acknowledge that the Yoga Teacher is NOT medically qualified
Please confirm that you have read and agree with the declaration above *
First Name *
My First Name
Last Name *
My Last Name
Email Address *
My Email Address
Are you happy to be added to my mailing list? *
Phone Number *
My phone number
Date of birth *
MM
/
DD
/
YYYY
Emergency Contact Name *
My Emergency Contact's name is...
Emergency Contact Numer *
My Emergency Contact's number is...
Please indicate if any of the following apply to you *
Required
Are you, or have you been pregnant in the last 12 months? *
What other types of exercise do you participate in? *
I participate in...
Please confirm that the above information is correct *
Thank you for taking the time to fill out my Health Questionnaire, I look forward to seeing you online or in class.
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