Yoga Registration Form

    Personal Details

    Your Name

    Your Email

    Your Date of Birth

    Your Phone

    Your Address

    Your Health Information

    1. Please describe the current state of your health:
    PoorAverageGoodGreat

    2. Are you taking any long-term prescription or over-the-counter medication?
    YesNo

    3. Do you suffer from any of the following?
    AllergiesAIDS/HIVAsthmaBack PainChronic FatigueEpilepsyFibromyalgiaGlaucomaHearing LossHeart TroubleHerniaHypertensionOrthopedic ProblemsPregnancy (due date)Respiratory ProblemsSurgery (recent)

    4. Please describe any other health or medical conditions below:

    5. Please ask any questions or voice any concerns that you have about participating in yoga classes:

    6. Is there anything else we should know about you or your health?

    I accept the terms of the Professional Yoga Disclosure and Release Form.

    Once you register above, please purchase your ticket.