Calgary Mysore

Ashtanga Yoga 

 

WAIVER FORM

Please note: All information on this form is kept confidential

***Please complete both pages***

 

Date:

 

REGISTRANT DETAILS: 

 

Name: _______________________________________________________ 

 

Male / Female 

 

Address: _______________________________________________________

 

City: __________________________ Postal Code: ____________

 

Email: _________________________Telephone: ______________

 

 

EMERGENCY CONTACT AND TELEPHONE NUMBER: 

_______________________________________________________

 

Have you practiced yoga before? Yes __________ No__________ 

 

If YES, for how long? _________ Which style of yoga? ________

 

What are your reasons for practicing yoga? 

 

___ Stress reduction                       ___ Weight management 

___ Mental clarity                            ___ Flexibility 

___ Spiritual growth                        ___ Strength 

___ Overall wellbeing        

___ Confidence 

___ Managing a particular illness 

Specify: __________________________________________________________________________________________________________

 

Other reasons 

Specify: __________________________________________________________________________________________________________

 

Are you currently experiencing any of the following conditions? 

 

___ Asthma                                                ___ Dizzy spells / Fainting 

___ Low blood pressure                            ___ Epilepsy / Seizures 

___ High blood pressure                           ___ Diabetes 

___ Heart / Circulatory Problems           ___ Pregnancy 

___ Muscular injury 

___ Neck / Back / Spine injury

___ Joint injury (ankle, knee, hip, elbow, shoulder) 

___ Recent surgery 

Specify: _______________________________________________________

 

Other medical condition, injury or disability 

Specify: _____________________________________________________________________________________________________________ 

 

If you are currently taking medication or have any serious allergies that should be made known to medical personnel in case of an emergency, please indicate them here: 

 

 

 

Waiver 

Asana (yoga posture) means posture easily held. If at any time during the class, you feel discomfort or strain, gently come out of the posture. You may rest at any time during the class. It is important in yoga that you listen to your body, and respect its limits on any given day. 

 

I, the undersigned, understand that Yoga is not a substitute for medical attention, examination, diagnosis or treatment. I should consult a physician prior to beginning any activity program, including yoga. I recognize that it is my responsibility to notify my teacher of any serious illness or injury before the yoga class. I will not perform any postures to the extent of strain or pain. 

 

I accept that neither the instructor, nor the hosting facility (Mysore Calgary & Pegasus Gymnastic @ 11166- 42nd St SE Calgary, Alberta) is liable for any injury, or damages, to person or property, resulting from the taking of the class. Those under 18 years of age must have this form signed by a parent or guardian. 

 

_______________________

Date 

________________________________________       ____________________________________________ 

Name (Print)                                                       Signature

_______________________

Date 

 

_________________________________________     _____________________________________________

Parent/Guardian (Print)                                    Signature

"Encourage One Another and Build Each Other Up”

Calgary, AB, Canada