Yoga Happens Here Portal

SECURE SITE CONNECTION

Your information is private and secure when using this form.

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Area CodePhone Number

Email*

example@example.com

Birthdate*

Date

Age

Sex*

MaleFemale

Do you have now, or have you had within the past year...*

	YES	NO
History of Heart Problems?
High Blood Pressure?
Muscle, joint or back disorder that could be aggravated by physical activity?
Surgery?
Diabetes?
High blood cholesterol?
Asthma?
Osteoporosis?
Do you smoke?
Are you presently taking any medications?
Are you now, or have you been pregnant within the last three months?
Allergic/sensitive to fragrances?

If you answered YES to any of the above (except smoking), do you have your doctor's permission to exercise?

YESNO

I have truthfully and honestly disclosed all medial issues I have above. I waive any possibility of personal damage and waive any liability against Paula Bayer and Yoga Happens Here which may be blamed on such an exercise-yoga program and accept full responsibility for requesting such exercise and instruction. I voluntarily assume complete responsibility for my health and well-being in the voluntary yoga program or class and understand that no responsibility is assumed by Paula Bayer and Yoga Happens Here.

I am also ok with photos/video that may contain my image to be used in marketing material on websites and/or Facebook for promoting Yoga Happens Here.

* As a reminder, out of respect for our students/staff that have allergies to such, please limit the use of fragrance such as perfume or cologne while attending a class. Thank you!

*

By checking this box, I agree to the above statement.

YOGA HAPPENS HERE