Registration Form Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *AgePhone Number *Address Line 1 Address Line 2Pin Code Do you have any medical/physical conditions shown below? all information is strictly confidentialHigh Blood PressureLow Blood PressureEye/Ear Problems (glaucoma, detached retina)SciaticaWrist ProblemsArm/Shoulder InjuriesArthritisKnee InjuriesNeck IssuesBack ProblemsHeart ProblemsPregnancyDiabetesFibromyalgiaDizzinessScoliosisAnxiety/Mood DisordersOtherIf you selected "other", please explainAre you presently taking any medication? If yes, provide detailsNoYesIf yes, please provide details.Have you consulted your physician about taking this class?YesNoHave you attended any yoga class before?YesNoAre you a yoga instructor?YesNoIf yes, please provide details (when, where, for how long, style of yoga practiced, etc.)What do wish to achieve in this class?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 acceptI declineSignature & Date Submit
