Name *

First Name

Last Name

Phone

(###)

###

####

Date of birth *

MM

DD

YYYY

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

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Do any of these apply to you?

This helps us tailor classes appropriately

Pregnant

Postnatal

Perimenopause/menopause

Estimated due date or birthday of most recent baby

Leave blank if not applicable

MM

DD

YYYY

Are you currently experiencing any of the following?

Select all that apply

Nausea

Headaches

Diabetes

Heartburn

Nosebleeds

Sciatica

Asthma

Lower back pain

Low blood pressure

High blood pressure

Depression

Anxiety

Dizziness

Pelvic Girdle Pain

Carpel Tunnel Syndrome

Hot flashes

Client declaration *

As far as I am aware, I have disclosed all information regarding my health relevant to the practice of yoga. I take full responsibility for all applications of yoga I practice in and outside of the class. I fully understand that the recommendations, ideas or techniques expressed and described in these yoga classes cannot be regarded as substitute for the advice of a qualified medical practitioner. Any uses to which the recommendations, ideas and techniques are put are at my sole discretion and risk.

Agree