Name
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First Name
Last Name
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
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Date of Birth
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MM
DD
YYYY
What pronouns do you use? Or if you prefer to be referred to by name only, please indicate that here.
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Occupation or Vocation
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Referred by:
First Name
Last Name
Emergency Contact Name
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Who can I contact in case of emergency during a session?
First Name
Last Name
Emergency Contact Phone
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(###)
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####
Have you ever practiced yoga before?
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What do you hope to get out of our sessions?
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Check all that apply
If "Other," please explain
Please list all forms of physical activity you currently engage in and how frequently (ie. walking -1 mile/day , zumba - once a week, etc.).
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Please indicate your current health status in as much detail as possible.
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Please indicate any current injuries or conditions, as well as complaints (aches, pains, etc.).
Please briefly describe your medical history (past surgeries / chronic conditions / health concerns)
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Are you currently under the care of a physician for any of the above injuries/conditions? If yes, please specify which one(s).
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Are you currently pregnant?
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Please indicate your pregnancy / birth history if applicable.
Include dates, nature of delivery (vaginal or cesarean), special circumstances (if comfortable to share).
Please list any medications you are currently taking.
Are you interested in private yoga sessions or group classes? Virtual or in person?
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Please select all that apply. Subject to availability and location.
Please share the goals you wish to achieve through a yoga practice?
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Is there anything else you would like Kate to know ahead of your first session or class?
I understand that yoga includes physical movements as well as an opportunity for relaxation, stress reduction and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor. I assume full responsibility for any and all damages which may incur through participation. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. By signing, I affirm that a licensed physician has verified my good health and physical condition to participate in such a fitness program. In addition, I will make the instructor aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician’s approval to participate. I also affirm that I alone am responsible to decide whether to practice yoga and participation is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Kate Howell. I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. I am signing this agreement voluntarily and recognize that my signature serves as complete and unconditional release of all liability to the greatest extent allowed by law in the State of Pennsylvania.
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