Yoga for Youth PRE-EXERCISE SCREENING SYSTEM

PRE-EXERCISE SCREENING SYSTEM

Participant Details
Name of Yoga Participant*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant Email (for older teens who may also like to be emailed directly)
example@example.com
Age*
DOB*

MonthDayYear
Date
Gender*

MaleFemalePrefer not to sayNon-binary
Next of Kin - Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Parent / Guardian Email*
example@example.com
Do you have or have you ever had any of the following (Tick Applicable):*

Heart disease Or any cardiovascular conditionsAny history of heart disease in your familyDizziness, blackouts, fainting spells, strokeAsthma or other respiratory problemsArthritis or other joint/muscular problemsMajor illness or surgery in the last 5 yearsHigh blood pressureDiabetesEpilepsyBone/Joint problemsBack problemsSports injuryHernia/Digestive issuesAllergiesAre you pregnantDo you have any pelvic floor concernsOtherNone - move to next questionOther
If you ANSWERED ‘YES’ to any of the above questions, please seek guidance from an appropriate allied health professional or medical practitioner prior to undertaking exercise.
Please provide additional information related to any of the above conditions if applicable:
Do you have any other conditions that may require special consideration for you to exercise?*
Other condition details
Are you currently taking any medication?*
Please list medication and reason for taking

Describe your current physical activity/exercise levels in a typical week by stating the frequency and duration at the different intensities. *

	Light	Moderate	Vigorous/High
Frequency (number of sessions per week) eg. 2
Duration (total minutes per session) eg. 20 minutes

Total minutes per week = (minutes of light + moderate) +(2 x minutes of vigorous/high)
Yoga History / Experience*
Would you like to receive a monthly update about future Yoga for Youth events via email?*

YesNo
What are the main reasons you have chosen to attend a Yoga for Youth session? (Tick all that apply to you)*

Improve physical health (strength, tone, posture, balance, flexibility, increase physical activity levels)Improve mental health (taking time out, practicing mindfulness, reduce stress, reduce feelings of overwhelm and overstimulation, reduce anxious feelings)Improve sleep qualityImprove connection with myself (slowing down so I can focus on myself and not everything going on around me)To connect with other teensTo try something newOther
If Other, please provide further detail. Please also elaborate if there is a specific reason for your yoga participation that you would like to highlight.

Disclaimer
Disclaimer

Yoga for Youth accepts no liability whatsoever in respect of any injuries, accidents, loss or damage to persons or property, arising from or in connection with any activity, exercise or training program offered or recommended by the Owner (owner means Yoga for Youth), its employees, servants or agents.

I hereby accept that exercise is not without risk or dangers and I certify that I accept and am fully aware of and comprehend all risks and dangers associated with exercise and related activities.

I certify that I have voluntarily accepted the abovementioned risks and dangers and have voluntarily elected to participate in yoga and exercise sessions.

I acknowledge and agree that at all times whilst under the direction of, or on the property of Yoga for Youth its employees, servants or agents, both of my property and my person shall be at my own risk.

I further acknowledge and agree that it is my personal responsibility to be covered by an accident or health insurance policy.

I hereby release to the fullest extent permitted by law the Owner, its employees, servants or agents from all claims and liabilities in respect of any injuries, accidents, loss or damage to my person or property, arising from or in connection with any activity, exercise or training program offered or recommended by the Owner, its employees, servants or agents, which includes but is not limited to aerobic workouts such as group exercise classes, the use of exercise machines, walks/runs, events entered into on recommendation of the Owner or its employees servants or agents, Resistance Training programs written by the Owner or its employees, servants and agents, fitness evaluation and any form of exercise co-ordinated by the Owner or its employees servants or agents.

I hereby indemnify in full the Owner, its employees, servants or agents from and against any and all claims, demands and liabilities to which the Owner, its employees, servants or agents is, or may be liable in respect of or in connection with any injuries, accidents, loss or damage to my person or property, arising from or in connection with any activity, exercise or training program offered or recommended by the Owner, its employees, servants or agents.

Client Consent

I agree to attend and adhere to guidelines set down by my instructor.

I acknowledge and agree that I have disclosed full details of any and all pre-existing physical injuries and medical conditions to Yoga for Youth prior to commencing any yoga sessions.

I acknowledge and agree that I am obliged to immediately advise Yoga for Youth of any changes to my health status, including but not limited to full details of any and all physical injuries and medical conditions. It is the recommendation of House of She that all clients seek qualified medical advice prior to the commencement of any exercise program.

I give permission for Yoga for Youth to use photos/video taken of me during Yoga for Youth yoga sessions and events for promotional purposes - advertising, social media etc. You are required to advise Yoga for Youth in writing if you DO NOT give permission for you photos to be used for promotional purposes.

I acknowledge and agree to the details and conditions set out in the above disclaimer.
Participant Signature - I declare that the information I have given above is true and correct to the best of my knowledge & agree to all conditions under the disclaimer*

Clear
Parent / Guardian Signature - I declare that the information I have given above is true and correct to the best of my knowledge & agree to all conditions under the disclaimer*

Clear
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