Yoga Registrations

Your name (required)

Your phone number (required)

Address

Your email (required)

Occupation

Date of birth

MEDICAL HISTORY

Have you had any major surgery? If so what & when?

Please give details of any injuries, fractures, dislocations and how long ago.

Do you have any of the following?
HIGH or LOW BLOOD PRESSUREHEART PROBLEMSASTHMAARTHRITISCARPAL TUNNELNECK PROBLEMSBACK PROBLEMSOTHER (please specify below)

OTHER

Are you pregnant or planning to be?
YESNO

If you answered yes in the previous question, when is your due date?

Do you have any further information including special medical/physical considerations that we should be aware of? (Please provide details)

YOGA EXPERIENCE

Have you practiced yoga before? If so, for how long and where / what kind?

What is it you would like to get out of yoga?
RELAXATIONSTRESS MANAGEMENTFLEXIBILITYSTRENGTHRELIEF FROM BACK or NECK PAINOTHER (please specify below)

OTHER

How did you find out about these classes?

INFORMED CONSENT

I have been informed, understand and am aware that strength and flexibility exercises including yoga are potentially hazardous activities.
I have also been informed, understand and am aware that these activities involve a risk of injury.
I am voluntarily participating in these activities and using equipment with full knowledge, understanding and appreciation of the dangers involved.

AGREEMENT

I understand that the instructions given throughout classes are intended only as a guidance. It is therefore my responsibility to:
1. Adjust my practice according to my limitation to ensure no personal injury occurs.
2. Inform the teacher before the class of any recent change to my physical condition.

I hereby declare that by submitting this form I release Danielle Mondahl and Thai Yoga Massage by Dani of any responsibility for any injury sustained and that I will take full responsibility for myself during the yoga classes.