Inner Light Yoga Center New Student Information
Name:______________________________ Home Phone:________________ CellPhone:______________
Address:_____¬______________________________City:_________________________ Zip:______________
Email:____________________________ Date of Birth____/_____/____ Occupation______________________
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/or Tai Chi Class, 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:______________________