Yoga participant intake form

Participant Intake Form

Community Yoga - Bomaderry & Surrounds
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Information
Please list any physical health concerns you may have
Please list any medication and supplements you are currently taking
Please list any allergies
Are you currently pregnant? Please advise if this changes.
Have you been hospitalised in the last three months?
Community Yoga - Bomaderry and Surrounds provided by Carla Balsar

I recognise yoga requires physical exertion that may be strenuous and may cause physical injury. I am fully aware of the risks and hazards involved. I understand that it is my responsibility to consult with a physician regarding my participation in yoga. I understand that if I am pregnant, I will take necessary steps to ensure my doctor and health care providers agree I can safely practice yoga. I agree to assume full responsibility for any risk, injuries, or damages, known or unknown, which I might incur as a result of practicing yoga. I knowingly, voluntarily, and expressly waive any claim against Community Yoga - Bomaderry and Surrounds provided by Carla Balsar for injuries or damages I may sustain as a result of practicing yoga.

I, my heirs, and legal representatives forever release, waive, discharge, and covenant not to sue Community Yoga - Bomaderry and Surrounds provided by Carla Balsar for any injury or death caused by their negligence or other acts.

I have carefully read this agreement and fully understand its contents. I have signed this release freely and voluntarily.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Participant Intake Form