Name *

First Name

Last Name

Phone *

(###)

###

####

Which classes do you want to book? *

Wednesday 23 April, 6am-6:45am

Wednesday 30 April, 6am-6:45am

Wednesday 7 May, 6am-6:45am

Wednesday 14 May, 6am-6:45am

Wednesday 21 May, 6am-6:45am

Wednesday 28 May, 6am-6:45am

Wednesday 04 June, 6am-6:45am

Wednesday 11 June, 6am-6:45am

1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke? *

Yes

No

2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise? *

Yes

No

3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise? *

Yes

No

4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? *

Yes

No

5. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months? *

Yes

No

6. Do you have any other conditions that may require special consideration for you to exercise? *

Yes

No

DECLARATION: I confirm that the information I have provided on this form is correct and I will notify the Teacher in the event that my circumstances change. I understand that the instructions given throughout the classes are intended only as guidance. I accept that it is my responsibility to adjust my practice according to my limitations to ensure that personal injury does not occur. I hereby declare that I take full responsibility for my own actions during the class. I also understand the importance of correct guidance and undertake not to pass on, nor teach, any of the techniques taught in class without full understanding and formal Yoga Teacher Training. *

Yes, I agree