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New Student Survey
First Name*
Last name*
Your email*
Emergency Contact Name & Phone Number*
How often do you exercise?*
Have you ever practiced yoga before? If yes, please provide details.
Yoga is safe for the majority of people, however, there are certain conditions which require special attention. If you are not sure please consult your doctor before starting any fitness routine. To help me ensure your safety and joy when practicing with me please check any boxes that apply to you belowYoga is safe for the majority of people, however, there are certain conditions which require special attention. If you are not sure please consult your doctor before starting any fitness routine. To help me ensure your safety and joy when practicing with me please check any boxes that apply to you below.
Abdominal Disorder or Rectal Injury
Anxiety/Depression
Arthritis (Oseto or Rheumatoid)
Asthma
Auto-Immune Disorder (eg MS, Lupus)
Back Pain
Diabetes
Epilepsy
Heart Disorder
High or Low Blood Pressure
Hip Problems
Knee Problems
Nerve Damage
Pregnancy/Recent Pregnancy
Sensory Disorder Effecting Eyes or Ears
Shoulder or Neck Problems
Other (note details below)
Other Health Disorder
Please give details of any injuries that may affect your ability to practice yoga.
I confirm the above information is correct. I take full responsibility for my health during yoga classes. I understand that it is my responsability to: Check with my GP prior to starting any new exercises if I have any concerns about my ability to perform them Advise the teacher of any change in my medical information or other, which may be relevant before the start of each class. Take full responsibility for not exceeding my physical limitations. Only do what feels comfortable and healthy for my body To inform the teacher if I experience any difficulty in class To practice mindfully and safely. I acknowledge that participation in yoga classes like all exercise exposes me to a possible risk of personal injur. I am fully aware of this risk and hereby release Chit Yoga, Lisa Hutton and any location or facility my class is at from any and all liability, negligence or other claims arising from or in any way connected with my participation in yoga classes.*
Agree
Submit
New Student Survey
First Name*
Last name*
Your email*
Emergency Contact Name & Phone Number*
How often do you exercise?*
Have you ever practiced yoga before? If yes, please provide details.
Yoga is safe for the majority of people, however, there are certain conditions which require special attention. If you are not sure please consult your doctor before starting any fitness routine. To help me ensure your safety and joy when practicing with me please check any boxes that apply to you belowYoga is safe for the majority of people, however, there are certain conditions which require special attention. If you are not sure please consult your doctor before starting any fitness routine. To help me ensure your safety and joy when practicing with me please check any boxes that apply to you below.
Abdominal Disorder or Rectal Injury
Anxiety/Depression
Arthritis (Oseto or Rheumatoid)
Asthma
Auto-Immune Disorder (eg MS, Lupus)
Back Pain
Diabetes
Epilepsy
Heart Disorder
High or Low Blood Pressure
Hip Problems
Knee Problems
Nerve Damage
Pregnancy/Recent Pregnancy
Sensory Disorder Effecting Eyes or Ears
Shoulder or Neck Problems
Other (note details below)
Other Health Disorder
Please give details of any injuries that may affect your ability to practice yoga.
I confirm the above information is correct. I take full responsibility for my health during yoga classes. I understand that it is my responsability to: Check with my GP prior to starting any new exercises if I have any concerns about my ability to perform them Advise the teacher of any change in my medical information or other, which may be relevant before the start of each class. Take full responsibility for not exceeding my physical limitations. Only do what feels comfortable and healthy for my body To inform the teacher if I experience any difficulty in class To practice mindfully and safely. I acknowledge that participation in yoga classes like all exercise exposes me to a possible risk of personal injur. I am fully aware of this risk and hereby release Chit Yoga, Lisa Hutton and any location or facility my class is at from any and all liability, negligence or other claims arising from or in any way connected with my participation in yoga classes.*
Agree
Submit
New Student Survey
Contact me
marvelous@chityoga.com
912-596-5687
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