Student Registration Form

Student Registration Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Phone Number*
Email*
example@example.com
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
To ensure your safety your medical information is required. Whilst Yoga may be practiced safely by the majority of people, there are certain conditions which require special attention, or modifications to be made. It is important to disclose ALL of your medical conditions so that your Teacher can determine whether a medical clearance from your GP will be required prior to participation in a Yoga class. The Teacher cannot provide medical fitness advice. If you have any concerns it is recommended that you speak to a medical professional. Should your health or medical condition change in the future, please inform your Teacher so as your student record can be updated accordingly.
Please indicate TICK if you have been diagnosed with the following conditions or exercise aggravates them:*

Heart ConditionStrokeChest PainDizziness/VertigoFainting (while exercising)AsthmaDiabetes Type 1Diabetes Type 2EpilepsyMuscle ConditionJoint Issue/ArthritisHigh Blood PressureLow Blood PressureHigh CholesterolSpinal Issues/PainHerniaThyroid ConditionChronic IllnessBroken BonesNo Current Medical Conditions
Do you have any other issues or concerns that may affect your practice?*

Yes (discuss with Teacher)No
Do you smoke?*

YesNo
Are you pregnant or have you given birth in the last 12 months?*

YesNo
Have you had any surgery in the last 12 months?*

Yes (discuss with Teacher)No
List any current medications:
How often do you exercise?
What is your level of yoga experience*

Complete beginnerHave tried it a few timesI Practice regularly
Do you consent to being contacted via email/sms regarding Yoga classes, workshops and events?*

YesNo
DECLARATION: I confirm that the information I have provided on this form is correct and I will notify the Teacher in the event that my circumstances change. I understand that the instructions given throughout the classes are intended only as guidance. I accept that it is my responsibility to adjust my practice according to my limitations to ensure that personal injury does not occur. I hereby declare that I take full responsibility for my own actions during the class. I also understand the importance of correct guidance and undertake not to pass on, nor teach, any of the techniques taught in class without full understanding and formal Yoga Teacher Training.

BOOKING CONDTIONS: I understand that bookings and upfront payment are required for all classes. I accept that cancellation fees apply if I fail to show up or cancel my booking within 24hrs. I will notify the Teacher if I am unable to attend the class for any reason. I will abide with the Covid Safety Plan.
Declaration*

Yes I agree with the above and accept the booking conditions
Signature*

Clear
Should be Empty: