Free Beings Yoga Student General Health & Registration Form

FREE BEINGS YOGA

STUDENT INFORMATION & REGISTRATION
Hari Om/Welcome.

To assist us in providing an appropriate service and assessment of your health and wellness please complete all fields. Your information is confidential.

Please arrive 10 mins pre-class to allow yourself time to settle and get comfortable.

YOUR PRIVACY
- All details provided on this form are securely stored in a password-protected account.
- Your contact details will NOT be passed on to any third parties and your personal details are not shared with any other class participants.
- Information is collected by Free Beings Yoga, to:
  - Ensure we understand any potential issues/injuries you may have so we can provide support and appropriate practices to accommodate your needs
  - In case of any medical emergencies or other emergencies
Full Name *

First Name Last Name
Mobile Number *

Prefix Mobile Number
Email *

Confirmation Email example@example.com
Emergency Contact. In the case of any emergencies please provide us with a contact number of someone close to you. *

Area code Mobile Number
Address

Street Address

Street Address Line 2

City Region/Province

Postal Code
Occupation
Age
Date of Birth *

Day Month Year
Gender

Male Female Prefer not to say
If below 18 years old (minor), please enter name of parent or guardian

First Name Last Name
Parent / Guardian Phone

Area Code Mobile Number
GENERAL HEALTH QUESTIONNAIRE
PART 1. Please tick if you have, or have had, any of the following conditions *

Back pain Consistent headaches Shoulder pain Numbness to any part of the body Muscular pain Neck injury Seizures Hip or Knee surgeries Allergies Surgery Low Blood Pressure High Blood Pressure Heart issues Digestive issues Reproductive/Menstrual issues Respiratory/asthma issues Kidney/Renal issues Addiction treatment Anxiety issues Panic attacks Recent Surgery Epilepsy Diabetes Other
If other - please note the issue and what you would like to let us know about:
PART 2. Please indicate if you have or have had any of the following conditions *

Muscle tightness or pain General tension Headaches Blood pressure issues
Are you currently pregnant? *

yes no
If yes, at what stage if your pregnancy :
Please indicate any medications you are currently taking:
Do you participate in regular exercise? *

Yes No
What type of yoga have you practiced before? *

Hatha yoga Yoga at the gym Power Yoga Yoga retreats/ Teacher Training Online yoga classes Other
If 'other' selected above, please indicate here:
Please indicate outcomes you would like to experience from undertaking these classes? eg: feel relaxed, reduced stress levels, more flexibility, reduced muscular tension etc *
ADVICE
If you have ticked any of the conditions in the General Health Questionairre, Part 1, you should check with your doctor for clearance and then ask for guidance from your teacher before commencing your yoga class and program.

You must be comfortable and pain-free throughout all activities. Remain within your personal limitations. If you experience pain or discomfort in any of the practices, stop and seek advice.

Should you suffer from any injury, illness or condition in the future, please inform us by completing this form again.

TEACHER QUALIFICATIONS
All Free Beings Yoga teachers are at a minimum 200 RYT Registered Yoga Teachers with the Yoga Alliance. All are Workplace First Aid qualified and registered with REPS - NZ Register of Exercise Professionals.
Consent Agreement
I, First NameLast Name would like to participate in a yoga class being offered by Free Beings Yoga.

I have answered the questions to the best of my ability and understand the advice given above. I also understand that Free Beings Yoga teachers cannot give medical advice with regard to my medical fitness and that the information I have given will be used as a guideline to the limitations of my ability for activities in class.

I agree to work within my own abilities and I do not hold Free Beings Yoga responsible for injuries, accidents or death. I fully understand that yoga is a physical activity that may or may not cause physical injury.

I agree to declare any health issue or conditions I may have before signing up for the program.

I agree to inform my teacher and/or consult a doctor before a yoga class should I have concerns about my physical, mental and emotional state of being.

If poses might be uncomfortable, any suggested modification can be discussed with me directly in a respectful manner. If there's any strain or fatigue, I can come out of the pose to rest and understand that everyone has their own physical limitations.

I fully recognise that any injuries sustained from all the physical activities will be my responsibility. Therefore I release Free Beings Yoga of any liabilities.

I have read and fully understand the terms of the agreement/waiver and accept all of it.
Please note: This Student Information & Registration Form may also be completed on hard copy upon arrival at the Yoga class.

Agreement to the above information and personal responsibility disclaimer is confirmed upon submission of this Student Information & Registration Form.
Date Signed *

Day Month Year
Should be Empty:

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FREE BEINGS YOGA

GENERAL HEALTH QUESTIONNAIRE

Consent Agreement