Date of Birth (IF YOU ARE UNDER THE AGE OF 18, THIS AGREEMENT MUST BE COMPLETED BY YOUR PARENT OR LEGAL GUARDIAN. PLEASE CONTACT marcie@nourishingbreathyoga.com FOR THE APPROPRIATE FORM). *
MM
/
DD
/
YYYY
Person to contact in case of Emergency: *
Your answer
Check any area where you have pain, problems, or limitations:
Please list all other physical conditions, limitations, concerns, or injuries
Your answer
Are you physically pregnant, or have you had a child within the past three months?