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Name: ______________________________________________________________Date of birth: ___/ ___/ ___ Address:_________________________________________________________________ 

Telephone (home):________________________ Mobile:__________________________

Email: _____________________________________________________________   E-Mailing list: Yes or No (pls circle)

Occupation: _____________________________Male/Female:______________________

Experience in yoga: ______________Types: ______________________________________ 

Are you pregnant: _____________ What other sports to you do? _____________________________________________________

What are you looking to gain from yoga? ___________________________________________________________________________ 

How did you hear about these classes: ___________________________________________

 

Do you have any of the following conditions? Please write Y for yes and blank for no.

Arthritis ____ Asthma ___ Allergies ___ Breathing difficulties ___ Do you smoke ___ Back Pain ___ Neck pain___ Hypoglycemia___ Diabetes___ High blood pressure ___ Low blood pressure___ Heart disease___ Cancer___ Major injuries/operations Please specify ___ Broken bones___ Headaches___ Other pain in the body___ Ulcers___ Hospitalised recently ___ Infectious disease ___ Any other condition you believe would be helpful for us to be aware:_____________________________________________________________________

 

I the undersigned will start classes under the following conditions. I know of no reason why I should not practise or study Yoga. I agree to follow the instructions given by the teacher in class.

 

I accept that I am fully responsible for myself during yoga class. I agree to work within my limits at all times and to ask for assistance from the teacher whenever needed. I accept that the teacher will challenge me during class, but understand that I must meet this challenge with respect and safety for myself at all times.

 

I accept and understand that this practise may result in injury or accident, and release Annick Fournier or any guest teacher, from any liability or loss while training, practising, studying or in the application of Yoga. I understand that a student with a pre-existing condition, injury or illness should consult with their medical specialist before starting a yoga practise, and should have their health professional monitor that condition as necessary throughout the training program. I will not hold Annick Fournier responsible for doing this. In case of an emergency,

 

I hereby authorise any licensed medical professionals to perform any acceptable medical procedures deemed necessary and I agree to bear all the expenses of such necessary treatment.

 

I understand that fees are non-refundable and non-transferable. I have read and understand all of the above.

 

Contact in case of emergency:

Name: _____________________________ Contact phone: ____________________________

Student's signature ________________________________ Date: ________________________

Parent/ Guardian if under 18 years of age ___________________________________________