NILI YOGA STUDIO
PARTICIPANT REGISTRATION, HEALTH HISTORY & INFORMED CONSENT
CONFIDENTIAL — PRIVATE PARTICIPANT INFORMATION
Privacy notice:
The information you provide will be handled confidentially with reasonable care and used for class registration, communication, and participant safety. It will not be sold or used for unrelated purposes without appropriate consent, except as permitted or required by law. Please share only information relevant to your safe participation.
1. PARTICIPANT INFORMATION
Date of birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Full name:
First Name
Last Name
Email:
example@example.com
Phone:
Format: (000) 000-0000.
Emergency contact name:
First Name
Last Name
Phone:
Format: (000) 000-0000.
Relationship:
2. HEALTH HISTORY & MOVEMENT CONSIDERATIONS
Please check any item that applies and add details below. This information helps the instructor offer safer options; it is not a medical diagnosis.
Health considerations:
Heart / blood pressure condition
Dizziness / fainting
Balance concerns
Recent surgery or injury
Back / neck / joint pain
Osteoporosis
Pregnancy / postpartum
Hernia
Other relevant condition
I have movement restrictions or have been advised to avoid certain activities
None of the above
Details, movements to avoid, allergies, or accommodations requested:
If your health or physical condition changes, please inform the instructor before class. Consult a qualified healthcare professional if you are unsure whether yoga is appropriate for you.
3. SAFETY ACKNOWLEDGEMENT & INFORMED CONSENT
• I understand that yoga involves physical activity and may include stretching, balance, weight-bearing, and changes in body position.
• I understand that participation has inherent risks, including muscle soreness, strains, falls, or aggravation of an existing condition.
• I will work within my comfort level, breathe normally, stop if I feel pain, dizziness, shortness of breath, or unusual discomfort, and tell the instructor when I need an alternative.
• I will tell the instructor about relevant health concerns and follow safety instructions. I understand that the instructor does not diagnose or treat medical conditions.
• To the extent permitted by applicable law, I accept the ordinary risks of participation. Nothing in this form is intended to waive rights or liabilities that cannot legally be waived.
Nili Yoga Studio | Confidential participant form
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NILI YOGA STUDIO
CONFIDENTIAL — PRIVATE PARTICIPANT INFORMATION
CONSENT, PRIVACY & SIGNATURES
4. EMERGENCY RESPONSE
If an emergency occurs, I authorize the instructor to contact emergency services and my emergency contact when reasonably necessary. I understand that I am responsible for providing accurate emergency contact details.
5. PARTICIPANT DECLARATION
I confirm that the information I have provided is accurate to the best of my knowledge. I have read and understood this form, had the opportunity to ask questions, and voluntarily choose to participate in yoga classes. I understand I may stop or modify any activity at any time.
Participant full name:
First Name
Last Name
Participant signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent / guardian name (if participant is under 18):
First Name
Last Name
Parent / guardian signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Thank you for practicing with Nili Yoga Studio.
Nili Yoga Studio | Confidential participant form
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