My Yoga At Home Registration Form
Welcome

The information collected on this registration form will only be used for the purpose of this initial interview and general class recommendations.

For your safety, it is highly recommended that you keep the Yoga Teacher informed of any physical and /or mental ailments or health concerns before starting the Yoga and Ayurveda Classes. Please let us know of any changes in your health and /or personal information.

Thank you.
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PERSONAL INFORMATION
Name *
E-mail Address *
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Phone *
Address
Age (Optional)
If pregnant, Trimestre of pregnancy
Postnatal Mom and Baby. How old is your baby?
How did you know about us? *
Required
What is your field of work? *
For Ex. Computer Engineer, Nurse, retail, construction worker
What are your working hours? *
Is there anything we need to know about
your health? List or describe any problems or complications you may have had.



 *
EMERGENCY CONTACT INFORMATION
Full Name *
Phone Number *
Relationship
PHYSICIAN/MIDWIFE INFORMATION
Phone Number *
Address *
YOGA/EXERCISE HISTORY
Have you practiced Yoga before? *
Required
If yes, How long for? and Which Yoga School did you follow?
If you are pregnant?  Are you physically active? Which sports/activities do you do?
Did you health practitioner prescribed Yoga to you? If yes, please choose from below.
Clear selection
Please provide us with name and contact info of the health professional who prescribed Yoga to you. Thank you.
Waiver
 We invite you to read the following statements carefully and If you have any questions, please ask us before signing.

As a student of this yoga class:

 1. I understand acknowledge that I am  to receive instruction in yoga theory and exercises only, and I will not hold my Yoga Teacher to any higher standard of care than that applicable to a school of Yoga theory and exercises.

2. I will give my highest attention to the well being of myself

3.I will work with patience and an open mind in the self‐discovery process.

4. I understand that there is a risk of injury associated with yoga as with any physical activity

5. I understand that If I move with care, intelligence, courage, applied safety and self‐awareness, the injury is unlikely. Should injury occur or complications arise, the instructor or the hosting facility is absolved of all responsibility.

6. I am fully responsible for the outcome of my yoga practice and my participation in this class

7. I understand that I should report any problems with my health to my physician and/or midwife.

8. I will keep my yoga teacher informed with any changes in my physical health.



I  further state that I have carefully read the foregoing release and know the contents thereof, and fully agree with it and understand it, and I sign the same as my own free act. *
Required
By checking the box below, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking the box below, you are waiving that right. After consent, you may, upon written request to us, obtain paper copy of an electronic record. *
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