New Student Questionnaire and Waiver
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Living Room Yoga New Student Questionnaire and Waiver
Name___________________________________
Birth Date___________________
Best Phone to reach you___________________________
Back-up Phone __________________________
Address______________________________________________________________________
City___________________________________ State_______ Zip _______________
Email ____________________________________________
Emergency Contact ____________________________________
Relationship_______________________
Phone________________________
What exercise do you do on a regular basis?
________________________________________________________________________________
Explain any difficulties you have with __Ears __ Neck __Knees __Back ___Joints __Blood Pressure __Heart ___ Lungs
Explanation:
____________________________________________________________________________________
____________________________________________________________________________________
Past Injuries/operations/pregnancy:
_____________________________________________________________________________________
____________________________________________________________________________________
How did you hear about Living Room Yoga?
__Driving by
__Facebook
__Linkedin
__I saw the Living Room Yoga car
__A Yoga student_________________________________
__SYTA Website
__Tampa Bay Wellness Magazine
__From my healthcare provider_____________________
__Flyer on my doorknob
__Living Room Yoga Website through internet search
__Flyer in coffee shop (which one?_______________________)
__Golf Ad
__Internet Yoga directory (Circle which one: Yoga Finder, Yogi Seeker, Kavala, Holistic Network, Yoga
Network,
Yoga Voice, Health and Yoga)
__Our newsletter
__St. Pete Times
__Natural Awakenings
Liability Waiver
I am aware that my participation in yoga may result in accident or injury, and I assume the risk connected to my participation. I certify that I have disclosed all relevant health problems to Living Room Yoga prior to beginning the program. I agree to take responsibility for my own safety by practicing yoga on an empty stomach, breathing properly throughout sessions, moving slowly in and out of postures, and letting the instructor know immediately if a position feels uncomfortable. I acknowledge that the instructor has not and will not render medical services, including medical diagnosis of my physical condition. I specifically agree that Living Room Yoga shall not be liable for any claim, demand, cause of action of any kind whatsoever for, or on the account of death, personal injury, property damage or loss of any kind resulting from or related to my use of equipment or participation in yoga on my premises or on the premises of Living Room Yoga. I agree to hold Living Room Yoga harmless from same. I have read the above release and waiver of liability and fully understand its contents. I signify by signing below that I voluntarily agree to the terms and conditions stated above from this date forward in all my dealings with Living Room Yoga.
____________________________________
Printed Name
____________________________________/___________________
Signature Date
