Please complete this form prior to attending your first class. Thank you
Name
*
Email
*
Phone Number
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Emergency Contact
*
Emergency Contact Details (Mobile)
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Age Group
Under 16
17 - 34
35 - 44
45 - 64
65+
Have you practiced yoga before
Yes
No
Which aspects of yoga interest you the most
Physical Postures
Relaxation
Breathwork
Meditation
Chanting
Improve health and wellbeing
A bit of 'me time'
Other (Please state below)
Details
Do any of these health conditions apply to you?
High blood pressure
Low blood pressure/fainting
Arthritis
Diabetes
Epilepsy
Heart problems
Asthma
Anxiety
Depression
Detached retina/other eye problems
Recent fractures/sprains
Recent operations
Back problems
Knee problems
Neck problems
Recent pregnancies
Currently pregnant
If you answered yes to any of the conditions above, please give details
Do you have any other conditions, which affect your mobility or are likely to cause you concern when doing Yoga? If Yes, give details:
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How did you first hear about this class?
Confirm your responsibility
- I take full responsibility for my health during the yoga classes. I will inform my yoga teacher of any medical changes.
*
Confirm information is correct
- I confirm that all information provided above is correct and up to date to the best of my knowledge
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Your information will not be shared with any 3rd party entities.
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