Private Yoga Instruction Intake Form
Heather Earl Yoga, LLC
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Full Name: *
Date *
Email: *
Phone Number:
Date of Birth:
Emergency contact name:
Emergency Contact phone number:
Please list any physical limitations, injuries, surgeries or other health concerns you may have:
Do you have any of the following
What would you like to accomplish through your yoga practice and with private instruction:
How much time are you able to dedicate to a home practice on a daily basis:
What are your physical goals within your yoga practice:
Are there any areas of your body you recognize as tight or holding stress:
What elements of a yoga practice are you most interested in exploring:
Please list previous yoga experience and types of yoga you have explored:
Please provide any other information you think might be helpful and supportive to your private session or home practice:
ACKNOWLEDGEMENT & WAIVERI *
I understand yoga includes physical movements as well as an opportunity for relaxation, stress re‐education, relief of muscular tension, and to improve mental focus. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I affirm that I alone am responsible in my decision to practice yoga. I certify that all “special needs” have been disclosed and understand that if I experience any pain or undue discomfort, activity should be discontinued and support should be sought from the teacher. In the event of an emergency, I authorize medical services to be called to render assistance and will be financially responsible for incurred expenses. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against Heather Earl, ERYT or Heather Earl Yoga, LLC.
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