Yoga Registration Form Please complete one form for every person who wants to take part in any of the sessions Twitter YOUR PERSONAL DETAILS First Name * Last Name / Surname * Gender * Male Female Other Date of Birth - dd-mm-yyyy * Address Line 1 * Post Code * Address Line 2 City * Mobile Number * Home Phone Number * Email Address * Emergency Contact First Name * Emergency Contact Last Name * Emergency Contact Number * YOUR HEALTH Please tick all of the following that apply and give details below: Illnesses Injuries Heart Condition Arthritis or rheumatism Skin Condition Epilepsy Depression Asthma Circulatory problems Allergies Diabetes Migraine / Headaches ME / Chronic Fatigue High Blood Pressure Varicose Veins Detached Retina Frequent Nose Bleeds Major illness or operation Anxiety / Panic attacks Joint problems Given birth within 3 weeks Pregnancy Have you done Yoga before * Yes No What would you like to achieve by practising yoga? * NOTES AND DECLARATION Hop On Yoga allows you to work at your own level to improve your flexibility, strength and general health. It is not competitive, and postures can be adapted with props to assist extension and increase mobility. To reduce the risk of injury, never force or strain yourself during poses. Menstruating women should not do inverted poses, strong backbends or reverse standing poses. Pregnant women should ask for specific advice. Those with special health considerations should consult their medical practitioner before performing any exercise. If you are receiving treatment from a medical practitioner, have recently had surgery or a serious accident or illness, or are on medication, please check with the teacher whether this class is suitable for your condition. The teacher cannot be held responsible for any injury incurred during the class, or any problem arising as a result of a medical condition. YOUR CONSENT We may use the information provided by you for the purposes of providing, monitoring, assessing and marketing Hop On Yoga and to inform you of information, offers, services and products from time to time. We will not sell, share, rent or otherwise distribute any personal information to third parties. Please confirm you are happy for us to do this * Yes No I have read and fully understand this form and accept the terms stated above. I confirm that, to the best of my knowledge, the answers given by me are correct and accurate. I know of no reason why I should not participate in any form of physical exercise or any activity suggested to me by an employee or representative of Hop On Yoga. I acknowledge that any suggestions from any such employee or representative are neither diagnostic nor prescriptive. I agree to notify you of any future changes to the above answers. You may use the information provided by me in this form together with any other information that I may provide to ascertain whether Hop On yoga is appropriate for me. Your Full Signature Name * Registration Date *