Full Name *

First Name

Last Name

Do you have other medical conditions? *

Yes

No

Have you recently done or are you currently doing Physical Therapy? *

Yes

No

Do you have a current yoga or meditation practice?

Yes

Sometimes

No

What is a doable time commitment for working toward your goals at home?

5-10 minutes daily

20-30 minutes (2-3x's a week)

Other?

Emergency Contact Phone Number *

(###)

###

####

Terms and Conditions *

I HEARBY AGREE TO THE FOLLOWING: That I am participating in a yoga class. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in yoga classes. I recognize that yoga requires physical exertion, which may be strenuous and could cause physical injury, and I am fully aware of the risks and vulnerabilities involved. I represent and warrant that I am of sound physical body and have no medical condition that would prevent my participation in yoga classes, and if I do or have had injuries, I have listed them above and spoke to the instructor in regards to the areas of my concern. In consideration for being permitted to participate in the yoga classes, workshops and events of Build Yoga, I knowingly, voluntarily and expressively waive any claim I may have against the instructor, the owner or leaseholder of the building, for injuries or damages I sustain. I HAVE READ THE ABOVE RELEASE ND WAIVER OF LIABILITY AND FULLY UNDERSTAND IT’S CONTENT. I AGREE TO THE TERMS AND CONDITIONS ABOVE.

I agree

Date

MM

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Date

MM

DD

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