CUSTOMER INTAKE FORM- YOGA

YOGA STUDENTS

Intake Form
NAME
PHONE #(S)
BIRTHDAY
FULL ADRESS
WE NEVER EVER SELL RENT OR SHARE EMAIL ADDRESSES OR OTHER PERSONAL INFORMATION W/ANYONE. IS IT OK TO INCLUDE YOUR EMAIL ADDRESS ON OUR MAILING LIST?

Yes No
OCCUPATION
HOW DID YOU HEAR ABOUT US?
IN CASE OF EMERGENCY, CONTACT
PHONE #
ANY YOGA EXPERIENCE? Briefly share.
ANY FITNESS EXPERIENCE? Briefly share.
WHAT IS YOUR INTENTION TO PRACTICE?
For Prenatal Student, Estimated Due Date

Month Day Year
Date
DOCTOR/MIDWIFE & LOCATION& #
Anything Dina at Kashmir Hands needs to know about your Pregnancy? IE; what # birth is this, any discomforts, any complications, any prior surgeries?
Please check the ones that apply:

Do you wear contact lenses? Are you diabetic? Do you suffer from frequent headaches? Do you suffer from seizures or epilepsy? Do you hold tension in specific area? Do you have skin allergies? Are you sensitive to touch or pressure? Do you suffer from back pain? Do you have high blood pressure? Do you suffer from stress? Any broken bones in the past 2 years? Other
PLEASE TAKE A MOMENT TO READ CAREFULLY THE FOLLOWING INFORMATION AND SIGN WHERE INDICATED.
THANK YOU. I agree that my participation in yoga & fitness classes involves movements, exercises, and postures of my body that I am not familiar with and may cause pain or injury. I hereby certify that I am in good health and have permission to participate in classes. I hereby knowingly assume as with any physical activity there is a risk of injury with yoga & fitness classes. I waive and release all my rights in claims against Dina Giugliano of Kashmir Hands Inc., its owners and employees, against mishaps or injuries which may arise from the participation in classes and from any accidents arising from being on the premises. I take full responsibility for myself and personal being.
Signature

Clear
Date

Month Day Year
Date
Photography: If Dina Giugliano of Kashmir Hands Inc. staff or news media take pictures of program activities to be used in Dina Giugilano of Kashmir Hands Inc, publicity or on our website:

Yes, Dina Giugliano & Kashmir Hands Inc. has my permission to use pictures of myself No, Dina Giugliano of Kashmir Hands Inc. may not use pictures of myself
Cancellation Policy –
Our time together is important. Unless there is an emergency, it is requested that you cancel your appointment 24 hours in advance. No show clients will receive a bill for the full rate, less than 24-hour cancellation notice will be charged 50% of the appointment fee. Gift certificates may be forfeited for cancellations with less than 24 hours’ notice. Gift certificates will be forfeited for no shows.

Lateness Policy –
We request that you arrive early for your appointment. If you arrive late for your appointment, the time left will be used to its best advantage

Communication Policy -
If Kashmir Hands staff needs to postpone or cancel class or an appointment last minute your payment can stay in escrow towards your next service at Kashmir Hands.
Kashmir Hands will communicate these emergency changes via email, text or phone call. Together we can make a difference.
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YOGA STUDENTS

PLEASE TAKE A MOMENT TO READ CAREFULLY THE FOLLOWING INFORMATION AND SIGN WHERE INDICATED.