Name *

First Name

Last Name

Phone *

e.g. 44 779 864 3589

(###)

###

####

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Date of Birth

note that month is first, then day

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you attended a yoga class before? *

Yes

No

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. *

These conditions require specific modifications to your yoga practice. If yes, please give details.

Abdominal disorder or recent surgery

Unspecified back pain/ problems

Joint replacement

Hip problems

Heart disorders

Low blood pressure

High blood pressure

Arthritis (osteo or rheumatoid)

Spinal injury

Knee problems

Shoulder or neck problems

Other (please give details)

None of the above

These conditions may affect your practice and so provide useful information for your tutor. *

Asthma

Anxiety/depression

Epilepsy

Respiratory issues

Sensory disorder affecting eyes or ears

Diabetes

Auto-immune disorder (e.g. M.E. M.S. Lupus etc.)

Balance affecting disorder

Migraine

Other (discuss with tutor)

None of the above

Please tick this box if you do not wish to declare medical information

Option 1

Option 2

Have you had any recent operations (in the last two years)? *

Yes

No

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? *

Yes

No

Are you /could you be, pregnant, or have you given birth in the last six weeks? *

Yes

No

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? *

Yes

No

DECLARATION *

I 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 tutor

Tick Box

In 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. *

Post

Email

Mobile phone(text/SMS)

None of the above