YOGA THERAPY AT MARRICKVILLE YOGA CENTRE

MARRICKVILLE YOGA CENTRE

YOGA THERAPY REGISTRATION FORM
In order for us to assist you with your yoga therapy goals, please take a moment to complete the following Registration and Questionnaire Form.

Please note - Your booking is not confirmed until we receive your registration form.
Already a Student at MYC? Yes / No
Name
Pronouns
Email
example@example.com
Phone
Address
Age
Occupation
Emergency Contact Name*
Emergency Contact Phone Number*
1. Please outline details of the injury or illness you are seeking help for
2. Please outline your experience of your condition.
3. If you are a practitioner, please outline how this affects your practice or specific poses.
4. On a scale from 1 (very mild) to 10 (very severe), rate the severity of your pain/symptoms.
5. Please outline any relevant medical history
6. Are you currently taking any prescribed medication? Provide details.
DISCLAIMER: / understand that yoga is a physical activity and / engage in this class at my own risk.
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