Public Class Intake Form & Waiver Greetings!Thank you for taking the time to complete this. I look forward to practicing with you soon. Name First Name Last Name Gender pronoun/s? she/her he/him they/them Birthdate Address Phone Number (###) ### #### Email * Yoga history: What kind of yoga have you practiced, and for how long? Anxiety Current Concern Past Concern Recurring Does Not Apply Arthritis Current Concern Past Concern Recurring Does Not Apply Back Pain / Injury - Lower Current Concern Past Concern Recurring Does Not Apply Back Pain / Injury - Middle Current Concern Past Concern Recurring Does Not Apply Back Pain / Injury - Upper Current Concern Past Concern Recurring Does Not Apply Neck Pain / Injury Current Concern Past Concern Recurring Does Not Apply Blood Pressure - High Current Concern Past Concern Recurring Does Not Apply Blood Pressure - Low Current Concern Past Concern Recurring Does Not Apply Depression Current Concern Past Concern Recurring Does Not Apply Diabetes Current Concern Past Concern Recurring Does Not Apply Disordered Eating Patterns Current Concern Past Concern Recurring Does Not Apply GI Tract Imbalance Current Concern Past Concern Recurring Does Not Apply Headaches Current Concern Past Concern Recurring Does Not Apply Heart Disease Current Concern Past Concern Recurring Does Not Apply Insomnia Current Concern Past Concern Recurring Does Not Apply Joint Problems / Pain Current Concern Past Concern Recurring Does Not Apply Pelvic Health - Incontinence Current Concern Past Concern Recurring Does Not Apply Pelvic Health - Pain Current Concern Past Concern Recurring Does Not Apply Pelvic Health - Organ Prolapse Current Concern Past Concern Recurring Does Not Apply Post Traumatic Stress Current Concern Past Concern Recurring Does Not Apply Respiratory Condition Current Concern Past Concern Recurring Does Not Apply Vertigo Current Concern Past Concern Recurring Does Not Apply Are you Pregnant? Yes No Is there any other health information you'd like to share? Were you referred by a practitioner? If so, please include there name and contact information. If not, how did you hear about my services? Liability Waiver * By selecting "yes" I hereby agree to the following: 1. That I am participating in Yoga Classes, Health Programs or Workshops offered by Light Wellness LLC and/or Emily Light during which I will receive information and instruction about yoga and health. I recognize that yoga requires physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. 2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Yoga Classes, Health Programs or Workshops. I represent and warrant that I am physically fit and have no medical condition, which would prevent my full participation in the Yoga Classes, Health Programs or Workshops. 3. In consideration of being permitted to participate in the Yoga Classes, Health Programs and Workshops, I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, which I might incur as a result of participating in the program. 4. In further consideration of being permitted to participate in the Yoga Classes, Health Programs and Workshops, I knowingly, voluntarily and expressively waive any claim I may have against Light Wellness LLC and/or Emily Light for injury or damages I may sustain as a result of participating in the program. 5. I, my heirs or legal representatives forever release, waive, discharge and covenant not to sue Light Wellness LLC and/or Emily Light for any injury or death caused by negligence or other acts. I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above. I am aware that Light Wellness LLC/Emily Light is here to serve me by sharing knowledge of yoga and health. By my participation in classes or activities with Light Wellness LLC/Emily Light, I agree to take full responsibility for not exceeding my limits in the practice of yoga and for any injury I might suffer in the practice of yoga. It is my responsibility to ascertain that there is no medical reason to prevent my participation. In consideration of Light Wellness LLC/Emily Light’s instruction, I waive any claim that I might have at any time for injury of any sort against Light Wellness LLC/Emily Light or any person or entity in any way involved therewith. I have carefully read the release, fully understand and agree to the above. Yes Thank you for taking the time to complete this form. I'm looking forward to connecting more soon.
