Please note: All information on this form is kept confidential
***Please complete both pages***
Male / Female
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
___ Managing a particular illness
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
Other medical condition, injury or disability
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:
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.
Name (Print) Signature
Parent/Guardian (Print) Signature