Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth (DD-MM-YYYY)Address 1Address 2CityState/ProvinceZip/Postal CodeCountryMobile Phone Home PhoneEmail *Emergency Contact Name * *FirstLastEmergency Contact Telephone NumberHave you attended a yoga class before?YesNoIf yes, how long have you practiced yoga and what style of yoga have you practiced?The following information is required to ensure your safety. Whilst yoga 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.Abdominal disorder or recent surgeryUnspecified back pain/ problemsJoint replacement hip problemsheart disorderslow blood pressureArthritis (osteo or rheumatoid)Spinal injuryknee problemsshoulder or neck problemshigh blood pressureOtherNone of the aboveThese conditions require specific modifications to your yoga practice. If yes, please give details.Further InformationThese conditions may affect your practice and so provide useful information for your tutor. *Asthma Anxiety/depression EpilepsyRespiratory issuesSensory disorder affecting eyes or ears DiabetesAuto-immune disorder (e.g. M.E. M.S. Lupus etc.)Balance affecting disorderMigraineOther (discuss with tutor)None of the aboveFurther InformationPlease tick this box if you do not wish to declare medical information Tick boxHave you had any recent operations (in the last two years)? *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 practice?Are you /could you be, pregnant, or have you given birth in the last six weeks?Do you participate in any other physical activity, e.g. gym, jogging, swimming, aerobics, cycling, walking or other? If so, how regularly do you do this?How did you hear about these classes?DECLARATION *I accept the terms of service belowI confirm the above information is correct and that I take responsibility for my own health and safety whilst participating in the yoga class. I also 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 yoga class • advise the yoga tutor of any change in my medical information or ability to participate in the yoga class • follow the advice given by my doctor and/or yoga tutorName & DateThis acts as your digital signature when submitting the formIn order to comply with the General Data Protection Regulations, it is necessary to check whether, or not, you are happy for me to retain your contact details, and to email you information I think will be useful to you, including training and events, and relevant updates. I only hold information when it is necessary for me to carry out my work, and when you have given me permission to do so. To ensure that I only communicate with you in the manner of your preferred choice, can you please indicate below your preference(s) or otherwise, when contacting you. Please note that you are able to amend these choices at any time by contacting your tutor.PostEmailMobile phone(text/SMS)None of the abovePreferred means of communicationSubmit
