All students are requested to fill the registration form prior to attending their first class. Dismiss

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Name *

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Email *

Phone Number *

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Which services are here for? *

Regular Yoga
Prenatal Yoga
Energy Healing
Yoga and Energy Healing

Do you have any medical/physical conditions shown below? all information is strictly confidential

High Blood Pressure
Low Blood Pressure
Eye/Ear Problems (glaucoma, detached retina)
Sciatica
Wrist Problems
Arm/Shoulder Injuries
Arthritis
Knee Injuries
Neck Issues
Back Problems
Heart Problems
Pregnancy
Diabetes
Fibromyalgia
Dizziness
Scoliosis
Anxiety/Mood Disorders
Other

If you selected "other", please explain

Are you presently taking any medication? If yes, provide details

No
Yes

If yes, please provide details.

Have you consulted your physician about taking this class?

Yes
No

Have you attended any yoga class before?

Yes
No

What are your goals for yoga/ energy healing?

Emergency Contact Person

Emergency Contact Person Phone Number

NOTE: Do not start any exercise or fitness program without carefully assessing your own state of health and level of physical conditioning, considering your age, any illnesses or injuries you are recovering from, doing some personal research, and if necessary consulting your personal physician. Do wear comfortable, loose clothing to class and carry a bottle of water. Listen to your body at all times and stop practice if you feel overly uncomfortable or feel pain. DISCLAIMER: I I certify that the above information is true and complete to the best of my knowledge and that I will not hold Still Within School of Yoga or my instructor liable for any mishaps or health complications arising from my participation in yoga class. Participation in yoga classes is entirely at my own risk and any loss, damage, injury or any other mishap will not be the responsibility of the class organizer or teacher. *

I accept
I decline

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