Pranasana Yoga
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Email *
Name *
Date of Birth *
Address *
Email Address *
Telephone Number *
Emergency Contact Name *
Emergency Contact Tel. No. *
If 'Yes' how long ago and what kind of practices did you do?
The following information is required to ensure your safety. Whilst yoga and tai chi may be practised safely by most people, there are certain conditions which require special attention. If you are unsure, please consult your GP before commencing class. Please tick the boxes below if you have any of the following medical conditions. These conditions require specific modifications to your yoga practice. If yes, please give details.
These conditions may affect your practice and so please provide useful information to your tutor.
Further Information
Please tick the box if you do not wish to declare medical information
Have you had any recent operations (in the last two years)?
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If yes to 'recent operations' add further relevant information below.
Do you have any old injuries that still trouble you? Or any other medical conditions not covered above that might be adversely affected by yoga or tai chi practice?
Are you /could you be, pregnant, or have you given birth in the last six weeks?
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Do you participate in any other physical activity, e.g. gym, jogging, swimming, aerobics, cycling, walking or other?
How regularly do you do this?
How did you hear about us? *
Declaration ~ I confirm the above information is correct and that I take responsibility for my own health and safety whilst participating in yoga/tai chi classes with Pranasana Yoga. I 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 sessions. I will advise the yoga/tai chi tutor of any change in my medical information or ability to participate in the yoga/tai chi sessions and will follow the advice given by my doctor and/or yoga/tai chi tutors to the best of my ability.  I understand that Pranasana Yoga are not responsible for my actions and decisions during the sessions. *
If you would like to hear about more of our events please say "Yes! :)"
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To comply with the General Data Protection Regulations, are you happy for us to contact you? *
Name/Signature *
Date *
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