Hatha Yoga, Restorative & Wellness Events Registration

Name

Email

Phone

Town

Occupation

Age

Are you currently doing any sport or type of exercise? If yes, please give details

Why have you come to Yoga and what do you hope to gain from it?

Have you done yoga before?

Yes

No

If yes, for how long and what style?

Have you ever practiced Pilates/Tai Chi/etc?

Yes

No

If yes, which?

Are you currently taking any form of medication? If yes, please give details

Please give details of any medical conditions which might affect your practice

Have you suffered any injury or undergone any surgery (i.e. cesarean section, knee surgery, etc) which could affect you Yoga practice? If so, please give details

Do you have any allergies or dietary requirements?

Yes

No

If yes, please give details

How did you hear about the class?

Emergency Contact

Would you like to keep in touch with Maryline's news of classes, workshops, audio and video material. If yes, we'll add you to our mailing list. Your details won't be shared with anyone else.

Yes

No

Responsibility for my health - Online and In-person By ticking this box I declare that as far as I am aware, I have disclosed to Yoga with Maryline all information regarding my health relevant to the practice of yoga and/or meditation. I take full responsibility over my health in the yoga sessions (face-to-face or online) and for all applications of yoga I may practice outside the classes both now and in the future. I understand that any uses to which the recommendations, ideas and techniques are put are at my sole discretion and risk. Should there be any medical changes I will consult my doctor and inform Maryline as my yoga teacher

Photography and Video - In-person classes From time to time photographs and video footage of classes may be taken for use in my marketing. No compensation or fee may be claimed for this usage, and permission is always asked at the time.

Yes by ticking this box I consent to photos of myself being used in films and photographs in any and all media, now or at any time in the future.

No by ticking this box I do not consent to photos of myself being used in films and photographs in any and all media, now or at any time in the future

Thanks for submitting!

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