Yoga Registration Form

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Please complete this form to register with Details by Nicole

Email *

First Name *

Last Name *

Would you like to receive emails from Details by Nicole? *

Yes

Phone Number *

Date of Birth *

YYYY

Address *

Emergency Contact Name *

Emergency Contact Phone Number *

Are you currently experiencing any of the following? *

Asthma

Muscular injury

Joint injury

Pregnancy

High blood pressure

Low blood pressure

Dizzy/fainting spells

Epilepsy

Seizures

Diabetes

None of the above

Other:

Required

If you selected any conditions in the prior question, have you been cleared with your doctor to practice yoga? *

Yes

Unsure

Not applicable - no conditions apply

Disclaimer - Please read carefully.

If at any time during the session, 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 it's limits on any given day.

I, the undersigned, understand that yoga is not a substitution for medical attention, examination, diagnosis or treatment. I should consult 'my doctor' prior to beginning any program, including yoga for my overall wellbeing. I recognize that it is my responsibility to notify my 'instructor' of any serious illness or injury before the yoga session. I will not perform any posture 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 participating in these sessions.

Please type your name in the box below to consent to this disclaimer.

Date of consent *

YYYY

A copy of your responses will be emailed to the address you provided.

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