Samasta Wellness & Yoga
Where there is Love there is Life...Ghandhi
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Yoga and Meditation
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Health Questionnaire and Waiver
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Please note
to Register
you need to fill out a
Registration form
as well as this Waiver!
Samasta Wellness & Yoga Questionnaire and Waiver
*
Indicates required field
Name
*
First
Last
Email
*
Have you done yoga before?
*
No
Yes, at home
Yes, in a class
If Yes, what type and how long?
*
What interests you about yoga?
Please check as many interests as you like
*
Physical health and fitness
Mental health and emotional wellbeing
Stress relief/relaxation
Physical postures (asanas)
Breathwork (pranayama)
Meditation
Chanting/Kirtan
Other - please describe in comment box below
Do any of the following health conditions apply? If yes, please give details in the comment box below.
Please check all health conditions that apply
*
High/Low Blood Pressure
Arthritis
Back/Neck Problems
Knee Problems
Other Joint Issues
Recent Operations
Asthma
Smoker
Pregnancy
No known health problems
Have you ever been advised by you primary caregiver/physician to not engage in physical activity? :
*
Please choose, If yes please provide further information in comment box
Yes
No
Please give details of health conditions or any other conditions which may cause you concern when doing Yoga:
Comment
*
You hold the ultimate responsibility for your own
well-being
. If you have any doubt about your
well-being
always stop doing anything that causes you discomfort. Always avoid anything that causes pain or injury. Please ask your qualified instructor for assistance in finding comfort in the activity. This class/program is not intended to replace professional medical advice/treatment.
In signing this waiver, I understand that classes may be physically strenuous and I voluntarily participate in them with full knowledge that there is risk of personal injury. I agree that neither I, my heirs, assigns or legal representatives will make any claims of an kind whatsoever against Samasta Wellness & Yoga, the owners, its instructors or members for any personal injury, property damage/loss, or otherwise, caused by negligence or otherwise.
Please note: Completing this online form is an indication of acceptance and virtual signature
Participant or Guardian Signature
*
First
Last
Submit