Health Questionnaire / Terms & ConditionsPlease note: All of the information on this form is kept confidential. Name * First Name Last Name Choose age category Under 18 18-29 30-39 40-49 50-60 60-69 70+ Contact number * Email * Pregnancy Yes No Maybe N/A Do you have numbness/pain with the following: Neck Shoulders Hand Wrist Hips Hips Lower back Upper back Knees Feet Other If other please specify Emergency contact details: * Emergency contact name First Name Last Name Emergency contact number Course information * Attending course Workshop Class Yoga therapy Retreat Private session Other Why did you choose this? Have you practised yoga before? Yes No If Yes, how long have you been practising yoga? What is your reason for doing yoga? Relaxation Fitness Breathing Wellbeing Strength and flexibility If applicable, please mention any limitations/injuries Would you like to recieve emails and special offers from Discover Ease? Yes please No thank you How did you hear about us? Word of mouth Website Leaflet Google Any additional information you would like to share Waiver - I hereby agree to the following: 1. That I am participating voluntarily in a class or workshop offered by Yoga with Josie. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor. I am fully aware of the risks and hazards involved. I represent and warrant that I am physically fit and have no medical condition that would prevent my participation and I agree to assume full responsibility for any and all risks, injuries or damages, known or unknown, which I might occur as a result of participating in the program. 2. I understand that I may receive physical assists or adjustments to enhance my body posture during class by either an instructor or assistant in the class. I will take accountability for alerting the teacher of any injury or impairment in advance of the class or if I do not wish to receive any assists. 3. I knowingly, voluntarily and expressly waive any claim I may have against Yoga with Josie and its instructors for injury or damages that I may sustain as a result of participating in the program. 4. I, my heirs or legal representatives forever release waive, discharge and covenant not to sue for any injury or death caused by their negligence or other acts. 5. I understand that an area for personal belongings is available during the class, however, I agree that Yoga with Josie are in no way responsible for the loss or damage of any of my belongings while I attend class. 6. I understand that yoga is not a substitute for medical attention, examination, diagnosis, or treatment. I should consult a physician prior to beginning any activity program, including yoga. I recognise that it is my responsibility to notify my teacher of any serious illness or injury before every yoga class. I will not perform any postures to the extent of strain or pain. 7. I affirm that a licensed physician has verified my health and physical condition to participate in such a programme of exercise. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician's approval to participate. I also affirm that I alone am responsible to decide whether to practice yoga and participation is at my own risk. I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. By ticking the box below I am signing this agreement voluntarily and recognize that buy ticking the box below serves as complete and unconditional release of all liability. I hereby agree to irrevocably release and waive any claims that have now or may have hereafter against Yoga with Josie. I agree to the above waiver * I agree Thank you!
