Pregnancy Class Health Intake

Name

First NameLast Name

Email

example@example.com

Permission to email class/studio news & updates?

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Baby's Due Date

Date

How did you hear about classes?

Why have you decided to start Yoga/Pilates/Fitness in pregnancy? Please take a moment to note what you hope to gain from attending classes:

What aspects of your pregnancy & health would you like to concentrate on?

Are you currently experiencing OR ever been diagnosed with any of the following?

Is this your first pregnancy? If no, how many other children do you have and ages?

Have you had any complications with your pregnancy?

Any recent injuries/surgeries?

Is there anything related to your pregnancy that you feel you would like to discuss? (Help finding resources, birth support, etc)

I agree that I have been open & honest about my health.

Waiver & Release of Liability
Please read carefully before signing. This agreement includes a waiver and release of certain legal rights.

By participating in classes, workshops, private sessions, livestreams, videos, or other services offered by Divine Child Yoga LLC, I acknowledge and agree to the following:

I have consulted with, or have been advised to consult with, my healthcare provider regarding participation in prenatal exercise and have received approval to participate.
I understand that it is my responsibility to inform my instructor of any changes to my health, pregnancy, symptoms, or medical recommendations before or during class.
I understand that participation in prenatal yoga, Pilates, strength training, fitness, and other movement activities involves inherent risks. I voluntarily choose to participate and assume all risks associated with these activities.
I agree to listen to my body, work within my own abilities, and stop any exercise if I experience pain, dizziness, bleeding, contractions, leaking of fluid, shortness of breath, or any other concerning symptoms.
I release, waive, and discharge Divine Child Yoga LLC, including its owners, members, employees, contractors, instructors, volunteers, and agents, from any claims, liabilities, demands, or causes of action arising from my participation, except as otherwise provided by applicable law.
I understand that this waiver is intended to be as broad and inclusive as permitted by applicable law.

I certify that I have read and understand this Waiver & Release of Liability and voluntarily agree to its terms.

Signature

Today's Date

Date

Prenatal Movement Intake & Consent Form