New Student Intake

Welcome! Thanks for taking the time to fill out this form. It really helps me to know a bit about you and how I can best serve you.

Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

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Medical Information

Please give me a sense of your general health and physical capabilities so that I can instruct you to the best of my ability.

Injuries and Dates

Recent Surgeries and Dates

Physical Limitations

Chronic Conditions

Areas of tension or pain

Other Pertinent Information

Yoga Experience and Areas of Interest

Beginners are always welcome, but if you have previous experience, please tell me about it.

Have you done yoga before?

If yes, for how long?

Reason(s) for interest in yoga?

Click all that apply.

Physical fitness

Rehab or pain relief

Relaxation or stress relief

Mental focus

Spiritual practice

General Guidelines for Practicing Yoga

Listen and follow all instructions carefully. Ask the instructor if you are unsure how to perform a movement. Breathe smoothly and continuously as you move; do not hold your breath. Work gently, respecting your body’s abilities and limits; do not strain. Don’t perform movements that are painful. If you experience sharp shooting pain, come out of the posture at once.

Acknowledge

Click the box below to acknowledge that you have read and understand the above guidelines and that you recognize that these guidelines can help reduce your risk of injury.

I acknowledge the guidelines.

Release & Waiver of Liability

Please read carefully! This is a legal document, which affects your legal rights! In exchange for participation in yoga class with Mary Beth Thomas and mbt yoga, I agree voluntarily and without duress to the following: 1. WAIVER AND RELEASE I do hereby release and forever discharge and hold harmless Mary Beth Thomas and mbt yoga from any and all liability, claims and demands of whatever kind of nature, either in law or in equity, which arises or may hereafter arise from participation in the class. I understand that this Release discharges Mary Beth Thomas and mbt yoga from any liability or claim that I may have against Mary Beth Thomas and mbt yoga with respect to any bodily injury, personal injury, illness, or death that may result from participation in yoga even if caused by the negligence of Mary Beth Thomas or mbt yoga. I also understand that Mary Beth Thomas and mbt yoga does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health or disability insurance, in the event of injury or illness. 2. MEDICAL TREATMENT I do hereby release and forever discharge Mary Beth Thomas and mbt yoga from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment, or service rendered in connection with participation in this class. 3. ASSUMPTION OF THE RISK I recognize that there are certain inherent risks associated with yoga and I assume full responsibility for personal injury to myself and further release and discharge Mary Beth Thomas and mbt yoga for injury, loss or damage arising out of my participation in yoga, whether caused by the fault of myself, Mary Beth Thomas or other third parties. 4. OTHER I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Michigan, and that this Release shall be governed by and interpreted in accordance with the laws of the State of Michigan. I agree that in the event that any clause or provision of this Release shall be held to be invalid by a court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release which shall continue to be enforceable.

Agree to Release and Waiver of Liability

By selecting the box below and typing your name, you are agreeing to the above stated release and waiver of liability.

I agree to the release and liability waiver.

First and Last Name

Today's Date

YYYY