Alzheimer's clients-Registration Form
Welcome to Zen Active Birth with Saba. Kindly complete the registration form to sign up for the class.
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Email *
Name of person filling the form?
Relationship to the client?
First Name of client *
Last Name of client *
Contact Number *
Date of Birth of client *
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Please mention details about the onset of Azheimer's, stages, symptoms and relevant information about the client to support her/him  *
Health problems, allergies or any related injuries *
Fitness and health levels of the client before the diagnosis *
Indicate any hobbies, favourite books or activity the client used to or still interested in as a point of interest? *
Mention any pointers that pleases the client or disturb her/him to avoid or include during the session. Example, talk about the weather, enjoyed dancing, talk about movies, don't mention a certain event, etc.. Anything could be helpful.  *
Type of class *
Emergency Contact information in case of emergency. Please indicate your contact person and number *
Limitations and health conditions of the client(Please declare limitations or health conditions - if any) *
Briefly- Describe what are looking for through the practice of Yoga and how could it support you in this time of your or your loved one's life: *
Waiver
IMPORTANT! TO COMPLETE YOUR REGISTRATION,  PLEASE READ THE WAIVER AND CONFORM BELOW.

If at any time during the class, you feel discomfort or strain, please pause to rest. You may rest at any time during the class. It is important in all sessions that you listen to your body, and respect its limits on any given day.

I, the undersigned, understand that yoga and any well-being modality I am participating in, is not a substitute for medical attention, examination, diagnosis, or treatment. I should consult a physician prior to beginning any activity program, including yoga, breathing, etc. I recognise that it is my responsibility to notify my teacher of any serious illness or injury before every any c class. I will not perform any physical activity 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 HEREBY CERTIFY that the information provided in this form is complete, true and correct to the best of my knowledge. *
I HEREBY ACKNOWLEDGE  that I have read and understood the waiver and agree to as well. *
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