First name

Last name

Date of Birth

Day

Month

Year

Address

Phone

Email

Emergency Contact Name

Emergency contact number

Have you attended a yoga class before?

Yes

No

If yes, how long have you practised yoga for and what style of yoga have you practised?

Further information

Please tick this box if you do not wish to declare medical information

Further information

Have you had any recent operations (in the last two years)? Do you have any old injuries that still trouble you?

Or any other medical conditions not covered above that might be adversely affected by yoga practice?

Are you /could you be, pregnant, or have you given birth in the last six weeks?

Do you participate in any other physical activity, e.g. gym, jogging, swimming, aerobics, cycling, walking or other?

How regularly do you do this?

How did you hear about this class?

DECLARATION

I confirm the above information is correct and that I take responsibility for my own health and safety whilst participating in the yoga class, whether face to face or remote

I also understand that it is my responsibility to:

check with my doctor if I have difficulties or concerns about my ability to participate in the yoga class

advise the yoga tutor of any change in my medical information or ability to participate in the yoga class follow the advice given by my doctor and/or yoga tutor

remain on screen during remote yoga session and if I move off screen or outside of the teacher’s view, whether intentionally or not; no liability will arise on the part of the teacher

Signature

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Date

Add In order to comply with the General Data Protection Regulations, it is necessary to check whether or not you are happy for me to retain your contact details, and to email you information I think will be useful to you, including training and events, and relevant updates. I only hold information when it is necessary for me to carry out my work, and when you have given me permission to do so. To ensure that I only communicate with you in the manner of your preferred choice, can you please indicate below your preference(s) or otherwise, when contacting you.

Please note that you are able to amend these choices at any time by contacting me.your text

Means of Communication - please tick those ones you are happy to be contacted by

Post

Email

Telephone

DECLARATION

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