Change Yoga Health Waiver
Please complete our Health Waiver Form before your first class.
Email address *
Please notify the teacher of any injuries or illness prior to your first class.
Name *
Your answer
Date of birth *
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Address *
Your answer
Suburb
Your answer
Postcode *
Your answer
Mobile number *
Your answer
Occupation *
Your answer
Would you like to learn about special offers/discounts and upcoming events via email? *
Have you regularly practised yoga in the past? *
Have you had, or do you have any of the following?
Yes
No
Are you a male over 35 or female over 45 and not used to regular exercise?
Recent hospitalisation and/or surgery
Are you pregnant?
High blood pressure (>140/90) (if yes, please check with your doctor before commencing this exercise program)
Have you had, or do you have any heart condition? If yes, please detail below.
Your answer
If you answered yes to any of the questions above, please check with your doctor before commencing this exercise program.
If you have checked and been cleared by your doctor, please provide your doctors details below.
Your answer
Have you had, or do you have any of the following?
Yes
No
Gout, Stroke, Diabetes, Epilepsy, Hernia, Glandular Fever, Rheumatic Fever
Dizziness or Fainting
Arthritis, Asthma, Cramps, Muscular pain
Any pain/injuries to the neck, back, knees, ankles
If you answered "yes" above, please explain and add any other conditions that would cause you to modify your exercise program (please specify)
Your answer
How did you hear about us? *
Required
Terms & Conditions
I confirm and agree that the following terms, conditions and undertakings apply to the Change
Yoga exercise and training classes to be provided to me by Change Yoga & Wellness.

I have been examined by a licensed medical practitioner (“Practitioner”) within the past six
months and have been found by the Practitioner able to perform all vigorous stretching and the
Change Yoga & Wellness exercises, which I am to perform during my enrollment with Change
Yoga & Wellness.

I will faithfully follow all instructions given to me by Change Yoga & Wellness
and its teachers as to when, where and how to perform the instructed exercises. I agree and
acknowledge that participation in any Change Yoga & Wellness classes could constitute a risk
of serious injury to me, including permanent paralysis or death. I voluntary and knowingly
recognise, accept and assume this risk and warrant that I am physically fit and able to perform
the exercises provided.

I acknowledge that neither Change Yoga & Wellness, its owners,
teachers or employees shall be nor be deemed to be responsible or liable (whether in contract,
or in tort or under any statute whatsoever), for any injury, illness or mishap I sustain arising from
or out of, or in any way directly or indirectly connected with the Change Yoga & Wellness
classes.

I understand and acknowledge that I am to receive instruction in Change Yoga & Wellness
Classes and theory only. Change Yoga & Wellness, its owners, teachers, or employees are not
liable for, nor expected to provide any advice, training or medical assistance other than in the
form of the classes provided. I indemnify and will at all time hereafter well and sufficiently
indemnify and keep fully indemnified Change Yoga & Wellness, its owners, teachers or
employees from and against all actions, suits, causes of action, proceedings, claims, costs and
expenses whatsoever which may be taken or made against Change Yoga & Wellness, its
owners, teachers or employees or incurred or become payable by Change Yoga & Wellness, its
owners, teachers or employees of in connection with or arising out of any such injury, illness or
mishap to me.

The fees paid by me under this enrollment to Change Yoga & Wellness are non-refundable.
Change Yoga & Wellness may in its sole discretion grant refunds to me without prejudicing any
of its rights.
Signed *
Please type your full name below
Your answer
Today's date *
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