Pre-Yoga Form
House of She
Full Name
First Name
Last Name
What is your age?
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact : Name & Number
Check if you have any of the following issues:
Chest pain
Joint pain
Hip replacement
Knee Replacement
Arthritis
Musculoskeletal issues
High BP
Low BP
Asthma
Dizziness
Vertigo
Spinal issues
Visually impaired
Other
If you answered yes to chest pain, dizziness, musculoskeletal issues or spinal issues please provide further details here
Are you currently taking any medication?
Yes
No
Please list them.
Why are you practicing yoga?
Disclaimer - House of She accepts no liability, in respect to injuries, accidents, loss or damage to persons or property, arising from or in connection with any activity, exercise or training program offered. Participants take part at their own risk, and take full responsibility for their own safety and well-being. 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 above mentioned risks and dangers and have voluntarily elected to participate in yoga and exercise sessions
Accept
Decline and will not participate
Are you happy to be added to the House of She mailing list?
Yes
No
Signature
Continue
Continue
Should be Empty: