Yoga Health Form and Waiver

Yoga Health Form and Waiver
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

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CityState / Province

Postal / Zip CodeCountry
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

YearMonthDay
Date
Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
General Health

To help us serve you better please complete the following section as honestly as possible. Please note that all information provided is confidential.

Please indicate yes or no if any of the following apply to you*

Rows	Yes	No
Has your doctor at any time restricted you from strenuous activity?
Do you have high blood pressure?
Do you suffer from headaches/ migraines?
Do you have heart trouble?
Have you ever had a stroke?
Do you have osteoporosis?
Do you have arthritis?
Do you have asthma/respiratory problems?
Do you suffer from degenerative disc disease?
Do you have any neck or back pain?
Do you have shoulder pain or elbow pain?
Do you have hip or knee pain?
Do you have carpal tunnel?
Do you suffer from chronic fatigue or fibromyalgia?
Do you have an eye disease, such as retinal bleeding, glaucoma?
Are you pregnant?
Are you currently recovering from injury/surgery?

If you answered yes to any of the above, please provide further details below:
YesNo
If yes, please list them below.
YesNo
If yes, please provide details below.
YesNo
If yes, please provide details below.
SedentaryModerately ActiveInactiveActive
YesNo
YesNoIn training
YesNo
If yes, please tell us more. (style of yoga, for how long etc)
ExperiencedBasicIntermediateAdvanced
What are your expectations of the yoga class, if any?
Waiver and Release
NoYes
I expressly acknowledge that I will be engaging in yoga exercises that may involve inherent risks including, but not limited to, physical activity that may result in pain or bodily injury. I hereby state that I am and will be voluntarily participating in these activities and hereby assume all risks of injury which might result from these activities.

I, for myself, my heirs, executors, administrator and assigns, release and hold harmless the yoga teacher and it respective servants, agents, members, directors, officers, employers or employees from any claims, demands, damages, actions or causes of action arising out of or in consequence of any loss, injury or damage to my person or property incurred while practicing in yoga at any time or place, without limiting the generality of the foregoing, specifically, while attending or participating in yoga classes, yoga workshops or other meetings, notwithstanding any such loss, injury or damage may have arisen by directors, officers, employers or employees.

I hereby acknowledge that I have carefully read this waiver and release and fully understand that it is a release of liability of the yoga teacher and agree that such a waiver and release is reasonable and proper based on the nature of the activity.

I hereby waive and release the yoga teacher from any claims that I may have against the teacher with respect to any loss or theft of personal property while I am attending yoga class(es) in person.

I certify that I have read the above and I understand the terms of this agreement and the teachers/studio/clinic/school’s rules and regulations outlined (as provided when necessary) and I agree to abide by such rules and regulations.
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Yoga Health Form and Waiver

General Health

Waiver and Release