PRE-CLASS FORM

First Name*

Last Name*

Email Address*

Phone Number*

Emergency Contact Name*

Emergency Contact Phone Number*

Please give details of your yoga experience, if any...

Do you participate in any other physical activity? If so, please give details...

The following information is required to ensure your safety. Whilst yoga may be practised safely by the majority of people, there are certain conditions which require special attention and care. If you are unsure, please consult your general practitioner before coming to a class. It is your responsibility to ensure that the instructor knows of your medical conditions. If you have any of the following medical conditions, please tick them below…

abdominal disorderrecent surgeryarthritis (osteo or rheumatoid)back painknee problemship problemsshoulder problemsneck problemsheart disordershigh blood pressurelow blood pressureasthmadiabetesauto-immune disorderepilepsyanxietydepressionsensory disorderbalance affecting disorderother

Are you/could you be, pregnant, or have you given birth in the last six weeks?*
—Please choose an option—YesNo

Please tick the box to confirm that the information you have given in this form is accurate, and that you understand it is your responsibility to check with your doctor if you have any difficulties or concerns about your ability to participate in a yoga class.

Please tick the box to agree that you are responsible for notifying Geetu’s Yoga by email if any of this information changes.

Please tick the box to accept that Geetutpala Bordoloi Shah is not liable for any injury, or damages, to person or property, resulting from the taking part in this yoga class.