Inner Light Yoga Center Intro to Yoga Registration Date of Series:______________
Name:______________________________ Home Phone:________________ Cell Phone:______________
Address:___________________________________City:_________________________ Zip:______________
Email:____________________________ Date of Birth____/_____/____ Occupation______________________
Registration: without a mat purchase____ with Original Tapas 1/8” mat____ with Nature Collection 1/8" mat ___
___________________________________________________________________________________________
How did you hear about Inner Light Yoga Center? _______________________________________________
Have you practiced Yoga before? Yes No Type(s)___________________________________________
If Yes: How long have you been practicing?______________ How often do you practice?_________________
What are your goals for practicing Yoga:________________________________________________________
Please complete the following questions carefully. Yoga may be contraindicated if you have specific medical
conditions/symptoms.
My overall state of health is ___________________________________________________________________
Are you currently experiencing: (please check all that apply and comment where appropriate)
___ High Blood Pressure ___ Diabetes/Hypoglycemia ___ Scoliosis
___ Heart problems ___ Glaucoma or Detached Retina ___ Migraines
___ Osteoporosis ___ Joint injuries, limitations, pain ___ Asthma
___ Arthritis ___ Disc problems in neck or back ___ Allergies
___ Pregnancy ___ Pain in neck or back ___ Fibromyalgia
___ Chronic Fatigue ___ Sciatic or radiating pain ___ Muscle cramps
Please provide details on any item checked above or list any other significant medical condition you may have. (Use
back of page if more space is needed.)
Please list medications you are taking and for what reason: _________________________________________
_________________________________________________________________________________________
Please list other medical issues, major operations, accidents, or injuries (car accidents, surgery, etc): ________
_________________________________________________________________________________________
By signing below I understand and agree:
1.) That I take full responsibility for my body and my movements during Yoga and I will not hold my Yoga teacher or
Inner Light Yoga Center liable for personal injury arising from my participation in class.
2.) It is my responsibility to remind the Yoga teacher about my limitations and medical issues at the start of EVERY
class.
3.) If I experience any pain or discomfort at any time during a class session, I will immediately ease out of the pose
and inform the teacher so that the pose can be modified to meet my body’s needs and limitations.
4.) I understand that NO REFUNDS will be given for Class Cards or for the Intro to Yoga Series after the first class.
Student signature:______________________________________________ Date:______________________