Registration and Waiver Form Name * First Name Last Name Date of Birth * Address * Phone * (###) ### #### Email * How did you hear about us? * Emergency contact information Full Name * Phone number * Relationship * Health concerns Your medication details will be kept confidential and will not be discussed in class. They are requested to assist in the preparation of a class that is more tailored to your needs. Heart conditions Cancer High Blood Pressure Low Blood Pressure Wrist problems Arthritis Neck injury or pain Osteoporosis Upper back injury or pain Lower back injury or pain Diabetes Knee injury or pain Epilepsy Hip injury or pain Pregnancy Please list any other health concerns, injuries, allergies or medical conditions Movement background How would you describe your level of yoga experience? * Beginner Intermediate Advanced How many years have you practiced for? What style of yoga have you practiced before (eg. Hatha, Iyengar, Ashtanga, Flow, Bikram etc.)? What other forms of exercise do you do? * How many times a week do you exercise? * What are your primary goals in taking Be Still Movement classes? * These classes are being taught by a qualified yoga teacher. All care will be taken to ensure your wellbeing and safety. Any instructions given are intended as guidance only and you should not do anything that you consider inappropriate for you. These classes are not intended as a substitute for medical advice or care. Please consult your medical practitioner before you begin or if you have any questions or concerns about the suitability of these classes. Waiver and release of liability: By signing below, I acknowledge and agree to the following terms: 1. Assumption of risk I understand that the movements performed in Be Still Movement classes may involve physical exertion and carry inherent risks, including the risk of injury or illness. I acknowledge that I am voluntarily participating in these activities and fully assume all associated risks. 2. Health and fitness I confirm that I am in good health and physically capable of participating in Be Still Movement classes. If I have any pre-existing medical conditions, injuries, or concerns, I have consulted with my physician and have been cleared to participate in the classes. 3. Waiver of liability I hereby release, discharge, and hold harmless Be Still Movement, its owners, instructors, employees, and agents from any and all liability for any injury, loss, or damage I may suffer as a result of participating in Be Still Movement classes. 4. Personal responsibility I agree to listen to my body and not push beyond my physical limits. I understand that modifications and variations are available and that I am responsible for selecting the appropriate level of intensity for my practice. Agreement By signing this waiver, I acknowledge that I have read and understood the terms outlined above and agree to release the yoga studio from any liability. I understand that my participation is at my own risk. Full name * Date MM DD YYYY For minors If the participant is under 18 years old, a parent or guardian must sign below. Full name Date MM DD YYYY Thank you!
