Health Declaration

Please fill out the following form
in order to participate in a yoga class

First Name

Last Name

Date of Birth

Do you have a current injury or pain?

Yes

Are you suffering from a medical condition or illness?

Yes

If you answered yes to any question, please elaborate

Initials

Waiver: 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 every 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, is liable for any injury, or damages, to person or property, resulting from the taking of the class.

I declare that the info I’ve provided is accurate & complete.

Thanks for submitting!