Yoga Waiver & GDPR Form

1

Your Full Name

First Name

Last Name

2

Your EmailYour email address

example@example.com

3

Your Phone Number

Area Code

Phone Number

4

Do you have a disability?

YESNO

5

Have you had a major injury in the last 5 years:

YESNO

6

Are you taking any prescribed medication:

YESNO

7

Are you receiving treatment for any diagnosed medical conditions:

YESNO

8

Have you had any recent operations:Have you had any recent operations:

YESNO

9

Do you have or have you had any of the following:-back pain/ problems -Spinal injury -Joint replacement -Knee problems -Hip problems -Shoulder problems -Neck problems -Heart problem -High blood pressure -Low blood pressure

YESNO

10

Have you ever experienced any of the following symptoms; -Unusual shortness of breath with very light exertion -Pain, pressure, heaviness or tightness in the chest area -Unexplained pain in the abdomen, shoulders or arm -Severe dizzy spells or episodes of fainting -Regular lower leg pain during walking that is relieved by rest -Palpitations or irregular heartbeats -Are you currently pregnant or have you given birth in the last 6 months

YESNO

11

Do you have any other condition or injury not listed previously?

YESNO

12

Please give more details below if you have answered 'yes' to any of the above questionsi.e. What disability do you have? What injuries or conditions have you got? what operations & the dates of these. What medications you take? What restrictions in your body with movement you have, what pain you have? - thank you.

13

Please take care when filling in this questionnaire and check the contents are accurate before you submit it. By signing, you are confirming that the contents are true and accurate to the best of your knowledge. Please notify your teacher of any changes to your responses in this healthcare questionnaire before participating in classes subsequent to those changes.
Neither your teacher nor the Yoga Alliance Professionals are qualified to express an opinion that you are fit to safely participate in any yoga classes. You must obtain professional or specialist advice from your doctor before participating if you are in any doubt.
All of our yoga instructors are appropriately qualified, with high standards of teaching and best practice. Where possible, your teacher may offer suitable modifications or adjustments and practices to suit different levels of experience and ability.
Please always let the teacher know before the class if this is your first time practicing yoga or if you are not confident about your experience and/or ability. Where you have declared a health condition, please contact the teacher before the class if you would like to request that you are provided with suitable modifications or adjustments wherever possible.
In all classes, always follow your teacher’s safety instructions and listen to your body. Where a movement or class is beyond your experience or ability, feels too difficult for you, or you experience any discomfort, please do not continue the movement or class. In case that instructors provide physical adjustments, I understand that I have the option to opt-out by letting my instructor know my wish not have physical adjustments

I hereby release, waive, discharge and hold harmless the institution, its directors, officers, staff, volunteers, affiliates, and partners from any and all liabilities arising from any untoward incident in my participation to any class, workshop, and relevant sessions which may result to injury, loss, damage, or death.

By signing this form, I hereby represent and warrant that I am physically fit and capable to participate for yoga classes, workshop, or activities. I agree and legally bind myself, with full understanding to the contents and meaning of the provisions above. I declare that I am over 18 years of age and fully capable in giving my consent.

14

GDPR Statement - In order to comply with the General Data Protection Regulations, it is necessary for me to check whether or not you are happy for me to retain your contact details, and to send you information that I think may be useful to you like relevant updates. I only hold information when it is necessary to do so in order for me to carry out my work, and when you have given me permission to do so.

15

Do I have permission to contact you regarding Yoga?Agreement to the GDPR agreement above

YESNO

16

Do I have permission to use photographs featuring you during Yoga sessions on Social Media Platforms?

YESNO

17

Signature

18

Date