YOGA PHYSICAL FORM

Must be completed, signed and submitted prior to start of first class.

 

Please fill in the fields below using your keyboard.  You can tab from field to field for ease.

When complete, please print the form so that you can sign it.  Thank you.

 

Name:   Today's Date (00/00/0000):

Mailing Address (Street/PO Box):

City, State and Zip Code:

Home Phone:           Cell Phone:

E-Mail Address:

 

Occupation:   Age:

 

Emergency Contact Information

Name:   Phone Number:

 

Check Yoga Class Experience, if Any: Gentle  Beginner  Experienced

Check the Class You Are Registering For:  Tuesday at 6:00pm  Thursday at 6:15pm

 

Please give specifics regarding any illness or surgical procedure you have had within the past 18 months:

List any physical handicaps or chronic conditions which might be affected by physical exercise:

If you have chronic back problems, please list the areas of concern, what caused the injury (if you know), and the length of time you have had it:

What do you hope to gain from your practice of Yoga?

Please mention any other health concerns that might be helpful to your teacher.

 

AGREEMENT: This class involves physical activity.  I understand that participation includes the remote possibility of physical injury.  I hereby certify that the above information is true and complete to the best of my knowledge and that I will hold harmless the instructor, owner, director, board of directors and all affiliates of the space in which this class is held and Vijaya Yoga for any mishaps arising from my choice to participate in these yoga classes.

 

Adult Student's Signature: ________________________________________  Today's Date: _______________________