YOGA IS JOY STUDENT REGISTRATION FORM Name * First Name Last Name Email * Phone (###) ### #### What is your main motivation to practice yoga / meditation? Are you new to Yoga & Meditation? Are you participating in any exercise program ? If yes, what does it involve? Rate your level of stress * Low Middle HIgh Extreme Have you been treated or are you being treated for any of the following? * Heart conditions Respiratory conditions Spinal Injuries Muscle or bone injuries Cancer Blood Pressure Fertility issues Depression PPD or PTSD None of the above Other (Please specify below) Detail of Health Condition Have you ever had any of these therapies? Naturopathy / Homeopathy / Kinesiology Massage / Shiatsu / Acupressure Chinese Medicine / Ayurveda Physiotherapy / Chiropractic Reiki / Other energy work Are you on any medication or supplements that affect your capacity to exercise? If yes, please state known effects How did you find out about us? TERMS AND CONDITIONS: By submitting this document you agree not to hold Alexandra Di Cecco of Academy Kundalini Yoga, it's premises or personnel responsible for any losses, damages, injuries or liabilities. • The signee agrees he/she has been granted clearance by a physician to undertake an exercise program and he or she has no pre-existing problems that can be aggravated by exercise such as orthopaedic, blood pressure, cardiac or cardiovascular problems. • The signee recognizes that the instructor is not able to provide him or her advice in regards to medical fitness and that this information will be used as a guideline to the limitations of his or her ability to exercise. • The signee must advise the teacher of any relevant health issues before class start • Payment is requested upfront. • The signee agrees with the following cancellation policy: More than 24 hours - A makeup session must be scheduled within that week to avoid the full cancellation fee / Less than 24 hours - Full fee will be charged. • No refunds. * I accept these terms and conditions I fully understand the terms and conditions provided to me and have answered the questions above to the best of my ability and with this understanding, I electronically sign this form: * Thank you!
