Registration Form for Children's Program

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Isha Hatha Yoga for Children
www.hathayogawithhera.com
hathayogawithhera@gmail.com

Email *

Please fill in the information below to register your little Yogi(ni) to our Children's Program! All personal information will remain strictly confidential.

My Little Yogi(ni)

First Name *

Last Name *

Age *

Gender *

Male

Female

Other

Language *

English

French

Other:

Parent / Guardian

Name *

City *

Phone *

Emergency Contact Information

Please list details of someone to contact in case of emergency.

Name *

Relationship *

Phone number *

Health Information

Please indicate if child currently has any of the following conditions: *

Physical limitations

Communicable disease / Current viral infections

Asthma/ Respiratory conditions

Seizures/Epilepsy

Recent Surgery

Recent Injury

Attention Deficit Disorder / Hyperactivity

Autism Spectrum Disorder / Intellectual Disability

None

Other:

Required

If you have checked any of the above, please give details.

Allergy History

Please indicate if child currently experiences any of the following allergies *

Food allergy

Drug allergy

None

Other:

If you have checked any of the above, please give details of the nature of the allergy and the treatment required in case of emergency

How did you hear about us?

Please choose from options below *

Comments

Please share any questions or comments you may have.

Agreement

• I understand that what is taught during the Yoga workshops/classes are only for the child's personal practice, therefore will not teach to others.
• I understand that Isha Hatha Yoga are tools for healthy living, but the workshops are not a substitute for medical attention, examination, diagnosis or treatment.
• I understand that Yoga practice includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension.
• As is the case with any physical activity, the risk of injury is always present and cannot be entirely eliminated. Teaching will be done with attention and caution, and child can express any discomfort and seek out the teacher's advice.
• Yoga is not recommended and is not safe under certain medical conditions, therefore I will provide accurate information about the child's health condition.
• I hereby willingly wish for the child to attend this program completely. I take full responsibility for the result and indemnify the teacher, Hera Baboudjian, against all claims and suits. I will not communicate the contents of the program, either directly or indirectly to anyone else. I understand the participation guidelines and agree to follow them.

I hereby agree with the above statements and I declare that the above information is true, accurate and complete to the best of my knowledge. *

During our programs, we sometimes take photos for our portfolio / promotion /web content. At the end of the program we also take a group photo which can be shared on our website or social media. If you do not wish for the child to be photographed, or give permission for these intent, please let us know. *

I don't mind

I do not wish for child to be part of any photos

Date *

YYYY

Thank you! It will be a pleasure to have you join our Program!

Once we receive your completed Registration Form, we will email you to confirm this, along with details on payment modalities. Please make sure you have shared your correct email address and please contact us at hathayogawithhera@gmail.com in case you have not received any confirmation email in the following few days.

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms