REGISTRATION & HEALTH STATEMENT

REGISTRATION & HEALTH STATEMENT

Life Balance Yoga
Full Name*

First NameLast Name
Best Contact Number*
Mobile preferred
Email*
Confirm Email
example@example.com
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Emergency Contact Person
Name (relation to you)
Their Emergency Contact Number

Area CodePhone Number
Date of Birth

MonthDayYear
Sex

MaleFemale
Tick here to confirm that you agree to have your details stored electronically ?*

YesNo
Tick here to confirm that you want to be informed via email about holidays/cancellations/changes to classes.*

YesNo
These general classes are suitable for fit and healthy adults

Please understand that yoga is a physical activity which may result in injury. By completing this form, you undertake to participate in classes at your own risk. If you have any musculoskeletal problems, any of the health issues listed below, or any other health problem, please email details to the teacher before booking.
Please tick if you are currently or have you ever suffered from...?

Asthma or AllergiesAuto-immune conditionsCancerCrohn’s diseaseDetached retina/GlaucomaEndometriosis/Ovarian cysts/FibroidsEpilepsyHIV/AIDSHypertension (High Blood Pressure)/Heart disease/Cardiac problemsMeniere’s DiseaseMental health issuesMultiple SclerosisMyalgic Encephalomyelitis (ME)Nose BleedsOperation in the last 3 yearsOsteoporosis - arthritic conditionsParkinsonsPhysical disabilityPregnancyProlapseType 1 or 2 diabetesVaricose VeinsOther
If TICKED, Details...
If you have ticked any of the above boxes or have any condition not listed, please give details here
Have you had surgery in the last two years?

YesNo
If YES, Details...
Do you suffer from back pain?

YesNo
If YES, Details...
Do you have any injuries?

YesNo
If YES, Details...
Do you take any...?

MedicationsSupplementsNONE
If YES, please list...
Have you ever suffered from any of the following?

Digestive Problems (IBS, Bloating etc)AllergiesKidney ProblemsFood IntolerancesNONE

How would you rate your current physical fitness?

	1	2	3	4	5	6	7	8	9	10

1 is Poor, 10 is Athlete

How would you describe your nutritional habits?

BadGoodOptimalOther
How did you hear about Life Balance Yoga?
I heard about these classes from:

Internet searchReview site/another websiteFrom a friendAdvert in magazineAdvert in villageOther (please specify)Other
Please Read The Following T&C's.
By ticking the box below, I confirm that:

Cancellations

I understand that any cancellation needs to be made at least 72 hours in advance of a class and that if I cancel a class less than 72 hours in advance, I will be charged in full for that class.

Health

I have read and agree to comply with, the Coronavirus regulations that will be operational during my attendance at these classes.

I understand that yoga practice involves strong physical actions and I accept that such practice carries the risk of injury. I confirm that I have consulted my doctor about the advisability of participating in these classes where there are any doubts about my health.

All the information I have given on this form is correct to the best of my knowledge and that I agree to these terms and conditions.
I AGREE to the above terms and conditions.*

YesNo
LBY Number
After you submit this form, I will email you regarding your health statement and class suitability, along with your LBY number which you will need for booking classes.

To prevent this email and other future Life Balance Yoga emails from ending up in your junk or spam folder, please add my email address (leonorebunyard@gmail.com) to your address book.
Should be Empty:

REGISTRATION & HEALTH STATEMENT

These general classes are suitable for fit and healthy adults

How did you hear about Life Balance Yoga?

Please Read The Following T&C's.