Yoga Student Health & Consent Form

Personal Details

First name

Last name

Date of Birth

Day

Month

Year

Address

Mobile Number - choose dialling code & enter your number

Email

How did you hear about this class?

Emergency Contact Details

Emergency Contact Name

Emergency Contact Phone Number - choose dialling code and enter number

Age Confirmation*

I am 16 or over and give my own informed consent to participate.

I am under 16 – my parent or legal guardian will complete the consent section below.

Today's Date

Day

Month

Year

Yoga Background & Lifestyle

Have you practiced yoga before?

yes

no

Health & Medical Information

Are you pregnant or postnatal ?

Neither

Pregnant

Postnatal

Do you experience any of the following?

Shortness of breath with light activity

Chest pain or pressure

Unexplained pain (abdomen, shoulders, arms, etc)

Dizziness or fainting

Irregular heartbeat or palpitations

Leg pain during walking that eases with rest

Other

Touch Consent

Do you consent to gentle hands-on physical adjustments during class? (This will always be with prior verbal consent sought in class )

yes

no

Communication Preferences

Yes, subscribe me to your newsletter.

Privacy Policy

Your information will be kept securely and used only to support your safe participation in yoga classes, workshops or retreats. It may be shared with a cover teacher if needed. You can request your data to be removed or updated at any time. Full privacy policy available here.

Final Consent & Acknowledgement*

final consent & Acknowledgement

I confirm the information given is correct to the best of my knowledge

I take full responsibility for my health and wellbeing

I understand the risks involved and will practise within my own limits

I understand this information may be shared with a cover teacher

I release Maja McEwan from liability for any injury sustained

Signature (type name)