Atma Prema Wellness || Yoga Agreement & Waiver

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This should take you 2-5 minutes to complete and must be completed prior to first yoga session. Please answer these questions in full and to the best of your abilities and read the waiver and release statement at the bottom of this form. If something does not apply to you, please answer "N/A".

Email *

Personal Information

First and Last Name *

Email Address *

Phone Number *

Date of Birth *

YYYY

Occupation: *

Emergency Contact (Name, Relationship, Number):

Please list your regular hobbies/activities (so I can get an idea of movement):

What is your yoga experience?

Beginner

Intermediate

Advanced

What are your short term health/wellness goals? (optional)

What are your long term health/wellness goals? (optional)

Health History

Please list any allergies or sensitivities you may have:

Please list any medical conditions (including skin related) or physical limitations you may have that you want me to know about:

Any recent (within the last 2 years) accidents, injuries, pain, or surgeries?

How did you hear about yoga with Atma Prema Wellness?

Google

Facebook

Instagram

Referral (feel free to write their name in the 'other' section below)

Other:

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Please share anything else you would like me to know:

Agreement & Waiver of Liability

By signing this form, you acknowledge and understand that you have full autonomy and responsibility over your body, your safety, and your health. If at any point during class you feel discomfort or strain, gently come out of the posture. You are never required to put yourself in any position that does not feel safe or supportive and you are always welcome to rest and take breaks as needed. Yoga is not a substitute for medical attention, examination, diagnosis, or treatment. Please consult a physician prior to beginning any activity program, including yoga. It is your responsibility to notify the teacher of any illness, injury, or limitations before every yoga class.

I, the undersigned, accept that neither Alexandra Strong of Atma Prema Wellness (Teacher), nor The Yoga Branch (Hosting Facility), is liable for any injury, or damages, to person or property, resulting from the taking of the class. Those under 18 years of age must have this form signed by a parent or guardian.

FRAGRANCE FREE STUDIO *

Please refrain from using ANY artificial scents the day of your session. This includes perfume, cologne, scented hair spray, body products & lotions, and even clothes scented with laundry detergent/softener. This may seem like an unusual request, but for some people, including myself, these hormone disrupting chemicals cause headaches, hives, and breathing challenges and are very difficult to remove from the space and props. By checking this box, you agree to not wear fragrances into the studio. Thank you!

Required

By submitting this form and writing Your FULL Name in the space below, you acknowledge that you have fully read and accept the above Agreement and Waiver of Liability: *

Thanks for completing this form! PLEASE DOUBLE CHECK YOUR OTHER TABS (ESPECIALLY IF YOU'RE ON YOUR PHONE) AS WELL AS YOUR EMAIL, TO MAKE SURE YOU FULLY BOOKED YOUR YOGA SESSION!

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

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