STUDENT QUESTIONNAIRE

To be filled in when joining The Yoga Class

All information given will be treated in the strictest confidence and stored in accordance with Data Protection legislation.

Name:*
Date of Birth:*
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Address:*
Telephone / Home
Telephone / Mobile
E-mail:*
Emergency contact name and tel. no*
Have you ever attended a yoga class before?*
If YES, how long have you practiced yoga?
If YES, what style of yoga have you practiced? - (if known)
How did you hear about The Yoga Class?
Do you participate in any other physical activity, e.g. gym work, jogging, swimming, aerobics, badminton, cycling, walking or other?
How regularly do you do this?

The following information is required to ensure your safety. Whilst yoga may be practised safely by the majority of people, there are certain conditions which require special attention. If you are unsure please consult your GP before commencing class. Please tick the boxes below if you have any of the following medical conditions.

These conditions require specific modifications to your yoga practice. If YES, please give details.
if YES to any of the above give details
These conditions may affect your practice and so provide useful information to your tutor.
Are you/could you be, pregnant or have you given birth in the last six weeks?
Do you have any old injuries that still trouble you? Or any other medical conditions not covered above that might be adversely affected by yoga practice?
If YES to above, please provide details.
Have you ever had any operations in the last two years?
If YES please advise what the operation was.
PLEASE TICK THE BOX IF YOU DO NOT WISH TO DECLARE MEDICAL INFORMATION

DECLARATION

I Confirm the above information is correct. I understand that it is my responsibility to :-

  • Check with my doctor if I have any difficulties or concerns about my ability to participate in the yoga class

  • advise the yoga tutor of any change in my medical information

  • follow the advice given by my doctor/or yoga tutor

Re-typing your name below constitutes as an electronic signature
NAME*
Date:
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THANK YOU EVER SO MUCH FOR TAKING THE TIME TO COMPLETE THE FORM.

We very much look forward to seeing you in class!