BU Yoga - Health & Safety Form

Full Name

First NameLast Name

Contact Number

Email Address

example@example.com

Age:

Date of Birth:

Date

Gender:

FemaleMaleI would rather not say

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you signing up to take part in free yoga sessions at BU?

YesNo

If you are attending free BU Yoga - Do you need to borrow a yoga matt for the class?

Yes please!No thanks, il bring my own!

Have you practiced yoga before (it's fine if you haven't!)*

YesNo

Do you have any physical disability or health issues/ conditions I should be aware of?

YesNoOther

If yes, please can you kindly provide further details:

For females - Are you pregnant?

YesNo

Do experience any of the following?

If other or you would like to provide further detail, please do so below:

Please provide details of your next of kin (name, relationship and phone number):

By signing this document, I can confirm I am of the legal age and would like to participate in a yoga class being offered by Amy Martin.

I fully understand that yoga is a physical activity that may or may not cause physical injury. I agree to declare any health issue, conditions I may have before signing up for the program.

In the event that poses might be uncomfortable, any suggested modification can be discussed to Amy directly in a respectful manner. If there's any strain or fatigue, I can come out of the pose to rest and understand that each and every one has its own physical limitations.

I fully recognise that any injuries sustained from all the physical activities will be my responsibility. Therefore I release Amy Martin of any liabilities. I have read and fully understand the terms of the agreement/waiver and accept all of it.

Signature