New Student Form Adults

Are you 18 years old or over? (Under 18 need to fill separate form) *

Yes
No

Name *

First

Last

Address *

Email *

Mobile number *

Emergency contact name and telephone number *

The following information is required to ensure your safety. Whilst yoga may be practised safely by the majority of people, there are certain conditions which require special attention. If you are unsure please consult your GP before commencing class. Please give details below if you suffer with any medical conditions. These conditions require specific modifications to your yoga practice: abdominal disorder or recent surgery, arthritis (osteo or rheumatoid), back pain (if known cause please state), knee problems, hip problems, shoulder or neck problem, heart disorders, high blood pressure, low blood pressure. These conditions may affect your practice and so provide useful information for your tutor: asthma, diabetes, auto-immune disorder (e.g. M.E. M.S. Lupus etc), epilepsy, anxiety, depression, sensory disorder affecting eyes or ears, balance affecting disorder, autism, adhd, sensory disorders other (to be discussed with tutor). *

If female, are you pregnant? have you given birth in the last 6 months?

Yes, currently pregnant
Gave birth within 6 months
Not currently pregnant

Have you had any recent operations (in the last two years)? If yes, please provide details.

Are you happy for me to adjust you / use touch if required? *

Yes
No

From time to time it is possible the photo will be taken for marketing purpose. Do you agree for the photo of you being taken? *

Yes
No

Would you like to receive emails with forthcoming events and newsletters? *

Yes
No

How did you hear about this class? *

By submitting this form I agree to the declaration *

Yes I understand

I confirm the above information is correct and that I take responsibility for my own health and safety whilst participating in the yoga class, whether face to face or remote, and 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 tutor and remain on screen when participating in a remote yoga session. I also understand that yoga teacher is not a licensed medical care provider and is not able to diagnose, examine, or treat medical conditions of any kind, or in determining the effect of any specific exercise on a medical condition. • In all classes whether face to face, live streamed remote or pre-recorded remote, always follow your teacher’s safety instructions and listen to your body. Where a movement or class is beyond your experience or ability, feels too difficult for you, or you experience any discomfort, please do not continue the movement or class. I understand that throughout a remote session teacher’s view may be limited, whether intentionally or not; no liability will arise on the part of the teacher.

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