Yoga Registration Form

Yoga Registration Form

To register for Yoga classes with Karen Buckland...all information is confidential
Classes are for women and those identifying as women
Full Name *
Please include your surname
Which class do you wish to register for? Please select all times that would suit. *

Monday 10.00am Restorative Yoga for Term 1 Monday 7.40pm Yoga Nidra class for Term 1 Tuesday 10.30am Yoga Nidra class for Term 1 Tuesday 7.40pm Hatha for Term 1 Thursday 9.30am Hatha for Term 1 Friday 9.30am Yoga Nidra class for Term 1 Private class - please contact Karen to discuss availability Nurture Immersion Sat 11th Jan 10am - 12pm Nurture Immersion Sat 11th Jan 1pm - 3pm
Any notes you wish to make on the above classes you have selected?
Date of Birth *

Month Day Year
Your occupation *
Mobile Phone number *
Home Phone number
Email Address *
Please ensure email address is correct
Postal address (and residential address if different) *
Emergency contact person NAME AND phone number *
Please include the best phone number to contact emergency person on
Previous Yoga experience *

Never before Beginner (a little experience) Some experience Experienced
Are you currently pregnant? *

Yes No
Do you experience any of the following? *

High Blood Pressure Low Blood Pressure Heart Condition Glaucoma Hernia Back Pain Asthma Mental health issue Current Injury Limited mobility from a past injury Recent surgery Pregnancy related issue Other medical condition (provide details below) NONE
If you ticked ANY item of the previous question, please provide details of your condition:
Are you taking any medication? For what condition? Any side effects? Please provide details.
(For PRENATAL YOGA) - How many weeks pregnant are you? What is your EDD?
(For PRENATAL YOGA) - How many previous pregnancies? Please list your childrens ages.
(For PRENATAL YOGA) - List any complications or problems with previous pregnancies.
(For PRENATAL YOGA) - List any issues with CURRENT pregnancy to date
(For PRENATAL YOGA) - Obstetrician Name & Phone number
(For PRENATAL YOGA) - Your GP's name & Phone number
If there is something you may be sensitive to, such as being touched or receiving assistance, please note it here. Otherwise leave 'blank'.
What would you like to gain from yoga practice? *
eg. Relaxation, meditation, mindfulness, etc
Were you referred by a friend? If so, please let me know their name?
Is there any other information you wish to share?
RESPONSIBILITY AGREEMENT:

I agree to take responsibility for not exeeding my personal limits in yoga practice, and for any injury or discomfort which I may experience.

I agree to promptly advise my teacher, Karen Buckland, of any pregnancy, medical condition, or injury.

I understand it is my responsibility to consult with my medical practitioner in the case of any pregnancy / medical condition / injury, and to obtain his/her approval before participating in yoga classes.
Do you agree to the responsibility agreement? *

Yes, I agree to the responsibility agreement
Karen's Class Etiquette & Guidelines

* Bring along your yoga mat and a blanket. You may also wish to bring a water bottle.

* You may arrive 10 minutes before class if you wish. Please be respectful and maintain the quiet space.

* Yoga practice is best with an empty stomach. It's best to not eat for 1 hour prior; you may need longer.

* I endeavour to create a comfortable, secure space for students to practice yoga. If you have any concerns regarding this, please talk to me
Please indicate if you agree to the etiquette & guidelines *

Yes, I understand the class etiquette & guidelines
Terms & Conditions

* TURN OFF mobile phones before class.

* Arrive by the start time of your class.

* If you have any medical concerns, injuries, or if you are pregnant, inform Karen prior to class.

* Advise Karen (text message is preferred) if you are unable to attend a class.

* Payments for Yoga classes are non-refundable.

* Payments for Yoga classes are not transferable to a future date.

* For group classes, commitment is for the term. If you miss a class, you have the opportunity to attend a makeup class during the same term, subject to availability in the class.

*All makeup classes are to be organised through the private facebook group - Yogi's Hub. (New students will be invited to join the facebook group which is only for students)

*Karen holds the right to cancel or reschedule any classes, sessions, or events due to illness or other urgent situations. Karen will notify students of the rescheduled date.
Please indicate if you agree to the Terms & Conditions *

Yes, I agree to the terms and conditions
*
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