Yoga Intake Form

INTAKE FORM

Personal Yoga with Charlyn Fry
Name

First NameLast Name
E-mail
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date

DayMonthYear
Session Location
Have you practiced yoga before?
If Yes, for how long?
Do you have any pre existing injuries/ conditions/ limitations we need to consider? Eg: arthritis, surgery, allergies, health conditions etc.
If Yes, please provide information
If you do have any injuries/conditions or illness do you have your physicians permission to proceed with practice?
Additional Notes for Charlyn
New Yoga Student Waiver/Agreement

If at any time during the session, you feel discomfort or strain, you may gently come out of the posture/practice. You always have the option to omit or modify any posture/practice to support your needs. You may rest at any time during the session. It is Important in Yoga that you listen to your body and respect your limits on any given day.
YOGA STUDENT WAIVER/AGREEMENT: I hereby agree that I should consult a physician prior to beginning any activity program, including yoga for my overall wellbeing. I agree that it is my responsibility to notify my teacher of any serious illness or injury prior to every yoga session. I will not perform any postures or yoga practices to the extent of strain or pain. I accept that neither the teacher, Charlyn Fry, nor the Hosting Facility is Liable for any injury, or damages, to person or property, resulting from participation in the yoga session. I, the undersigned, understand that Yoga is not a substitute for Medical Attention, Examination, Diagnosis or Treatment.
By signing (draw your signature) below I certify that I am at least 18 years of age. I have read this Yoga Student waiver/agreement and fully understand the contents thereof. I agree that I have the legal authority to grant these permissions and accept all responsibility for such.
Should be Empty:

INTAKE FORM

New Yoga Student Waiver/Agreement