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Private Yoga Class Waiver Form
Please fill out this form with as much information as you feel is important for us to know before your class. All information is confidential and used to provide you with a safe and beneficial experience.
How many people will be attending this private class?
Please list the full names of all those attending
Contact Email
Contact Phone
Address
Birthday
If this class is for more than 1 person, please provide the age range of attendees (example 18 - 65). This doesn't have to be exact, just to give us a general idea of the group attending. Thanks!
Emergency Contact Name
Emergency Contact Phone Number
Have you practised yoga before?
No
Yes
Do you have any medical conditions or injuries?
*
No
Yes
Please check any existing conditions:
High blood pressure
Back/neck pain
Knee pain
Low blood pressure
Hip pain
Anxiety
Depression
Glaucoma
Pregancy (please include how far along you are)
Low blood sugar
Other
Provide other info or details of condition:
What would you like to ge out of this session? (Check all that apply)
I am new to yoga and would like a foundational class
I am an experienced yogi looking to advance my practise
I have an injury and am looking for modifications
I would like to develop a home practise so looking to learn a simple practise that I can do on my own
Looking for one on one instruction so that I feel more comfortable in group classes
Would like to work regularly one on one with a teacher
Looking for a special experience for me and my group
General Relaxation
Other
What style of class would you like?
Relaxing
Energising
Somewhere in between
Foundational / Beginner
Breathwork included
Meditation included
Not sure
I will practise mindfully and if at any time during the class, I feel discomfort or strain, I will gently come out of the posture. I know that I can rest at any time during the class. I will listen to my body, and respect its limits on any given day.
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.
I accept that neither the instructor, Evanachan Farm, nor West Coast Wellness, is liable for any injury, or damages, to person or property, resulting from the taking of the class and/or participating in this day retreat.
Date
Your Signature
Clear
Submit
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