Postnatal & Baby Yoga Client Intake
Divine Child Yoga LLC
Your Name
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First Name
Last Name
Email
*
example@example.com
Permission to email class/studio news & updates?
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Yes
No
Phone Number
*
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Baby's Name
*
Baby's Birthdate
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-
Month
-
Day
Year
Date
Does baby have any health concerns or allergies that we should know about?
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Emergency Contact Name & Phone
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Have you been cleared for exercise by your healthcare provider (usually at or around 6 weeks)?
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Yes
No
Have you had any of the following conditions in your medical history or during this pregnancy and postpartum time?
Heart disease
Hemorrage
Blood clots
Lung disease
Kidney disease
Depression
Anxiety
Major surgeries
High blood pressure/Pre-eclampsia/Eclampsia
Joint problems
Back problems
Neck injuries
Diabetes/Gestational diabetes
Other
Who can I thank for your referral?
*
Why have you decided to start yoga during postpartum? Please take a moment to note what you hope to gain from yoga classes:
In general, how are you feeling now?
Are there any other medical/mental/emotional issue that you would like Christie, the instructor, to know about and/or have questions about?
Any feelings about your birth or postpartum experience that you would like to share or address?
I agree that I have been open & honest about my & my baby's health:
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Yes
WAIVER & RELEASE OF LIABILITY - THIS AGREEMENT CONTAINS A WAIVER & RELEASE OF LIABILITY AND INDEMNITY AGREEMENT TO WHICH YOU WILL BE BOUND, AND UNDER WHICH YOU WILL BE WAIVING IMPORTANT LEGAL RIGHTS. DO NOT SIGN THIS AGREEMENT BEFORE YOU READ IT.* I understand that I should seek the advice of my physician before commencing any exercise routine.* I assume any and all risks of injury or illness associated with or in any manner related to my participation in and utilization of the classes, videos, and/or livestreams provided by Christine Trksak Gibertini (and under the group name "Divine Child Yoga LLC").* I agree and covenant not to sue or otherwise attempt to hold Christine Trksak Gibertini (or "Divine Child Yoga LLC") liable for any injuries regardless of the cause.* I agree to indemnify and hold Christine Trksak Gibertini (and/or "Divine Child Yoga LLC") harmless against any and all claims arising out of my participation in and utilization of the classes, videos, and/or livestreams provided by either aforementioned individuals or Divine Child Yoga LLC.* This waiver and release agreement is intended to be as broad as is allowed under the applicable law and applies to any and all claims for damages. Photo/Video Release: I hereby give permission to Divine Child Yoga LLC to use my or my child's name and photographic likeness in all forms and media for advertising, trade, promotion and any other lawful purposes. These materials will become the property of Divine Child Yoga. I authorize Divine Child Yoga to edit, alter, copy, exhibit, publish or distribute this photo/video image. In addition, I waive the right to inspect or approve the finished product wherein my or my child's likeness appears. I HAVE READ THE FOREGOING WAIVER AND RELEASE OF LIABILITY AND VOLUNTARILY EXECUTED THIS DOCUMENT WITH FULL KNOWLEDGE OF ITS CONTENT.
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Today's Date
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-
Month
-
Day
Year
Date
Submit
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