Student Intake Form
Yoga to Address Multiple Sclerosis and Other Movement Disorders


This form is confidential and to be used strictly for IYILA Specialty Course purposes.

Name *
Your answer
Phone Number *
Your answer
Billing Address *
Your answer
Email *
Your answer
Please list your condition (if known). *
Your answer
List current significant physical restrictions/symptoms. Please be as thorough as possible. *
Your answer
Do you require the use of a mobility assisted device? Please describe. (Cane, Scooter, Wheelchair, etc.) *
Your answer
Are you able to get up from and down to the floor unassisted? *
Will you be attending the class with a personal care giver? *
Your answer
List any neurological implants, if any (if none, write "none"): *
Your answer
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