Your Name (required)

Telephone

Address

Date of birth

Your Email (required)

Emergency Contact

Name

Telephone

Relationship

Yoga Experience

Have you practiced yoga before?
yesno

Do you practice any other sport or physical activity?
yesno

Yoga Goals

What are your yoga goals?
FitnessFlexibilityRehabilitationRelaxationMindfulness

Your Health

Do you have any medical condition, injuries or challenges I should be aware of?
yesno

Do you have or have you experienced any of the following in the past 6 months?
Heart conditionBack pain / injuryHypertensionMigraineDizzy spells, Loss of Balance/ ConsciousnessLow blood pressureEpilepsyAsthmaBone / Joint issuesChronic Fatigue

Have you had surgery or been pregnant within the last 12 months?
yesno

Release of liability:

I have no medical condition or injury that will prevent me from participating in yoga. It is my responsibility to inform the yoga teacher of any changes to my health. I will listen to my body and not push myself beyond my limits. I accept full responsibility for any risks, conditions, injuries or damages which I might incur because of my participation. I understand and acknowledge that Emma Young is a yoga teacher. I knowingly and voluntarily waive any claim I may have or acquire against Emma Young or associates over injury, conditions or damages. I understand and acknowledge that Emma Young and associates are not responsible for any loss, damage or theft or personal property.

I have read the agreement and fully understand the contents.

I’d like to occasionally receive email updates on offers and services from Emma Young Yoga