Registration Form – Free Spirit Wellness

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REGISTRATION FORM

**Please note, all of the information on this form is kept strictly confidential

Name

Phone

Email

Date of Birth

Address

Emergency Contact Name

Emergency Contact Number

Have you practiced Yoga Before? If yes, how long?

What is your motivation for taking this beginners series? What would you like to achieve from this workshop?

Do you currently exercise? If so, please specify what type of exercise and how often.

Current state of health? (Please select from Drop down)

Are you affected by any of the following? (Please select)

Heart problems of any type High blood pressure Multiple Sclerosis Asthma Low blood pressure Parkinson’s disease Glaucoma Detached retina Scoliosis Diabetes Headache Osteoarthritis Arthritis, bone or joint problem Chronic pain Pregnant Carpal Tunnel Syndrome Back injury Allergies Neck injury Knee injury Epilepsy Adrenal deficiency Arthritis Chronic sinus condition Fibromyalgia Sciatica None Other

If yes please describe in detail.

Release & Waiver of Liability

I agree to the following: 1. The information I have provided on this form is complete and accurate. 2. I understand that participating in an exercise class involves risk of injury; I agree to be solely responsible for any injuries sustained by me as a result of my participation in this class or any future classes I take with Sophia Gittings. I am fully aware of the risks involved. 3. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any Yoga class offered by Sophia Gittings. I represent and warrant that I am physically fit and have no medical conditions that would prevent me from participation in Yoga classes. I assume full responsibility for any injuries or damages, known or unknown, which I might incur as a result of participating in yoga classes. I knowingly, voluntarily, and expressly, waive any claim I may have against Sophia Gittings for injuries or damages that I may sustain as a result of participating in her yoga classes.

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