NurtureWorks Yoga & Qigong Registration Form • NurtureWorks Yoga

NurtureWorks Yoga & Qigong Class Registration Form

Claim your 4-Week Unlimited Class Trial by filling this in before your first session (or select one trial class).

You can register here for the following classes at the Signal Box Community Centre:

Hatha Yoga (Five Elements)
Well-Woman Yoga
Five Elements Qigong

For classes at Satyam Yoga studio, please register directly with Satyam.

Thanks for sharing your personal data. The information helps to make the classes safe, enjoyable and beneficial for all. Most questions are optional. Please focus on the sections relevant to and keep your answers concise, sharing only what you are comfortable with, while being sure to let me, as your teacher, know any key facts that I need to know about your health.

NurtureWorks is committed to safeguarding your privacy and will never share your data with third parties for marketing purposes. Your health data will be kept strictly confidential. See my Privacy Policy.

Please note - the trial offer covers my three regular weekly classes at the Signal Box.

Yoga and Qigong Class registration Stripe version

If you are human, leave this field blank.

First Name *

Surname *

Date of birth *

Email *

Address

Post Town/City

County

Postcode

Phone

Doctor's name & address

Doctor's Phone

Where did you hear about NurtureWorks? *

Would you like to receive NurtureWorks email updates - with Yoga, Qigong and well-being tips and videos, news about upcoming workshops and retreats and class-change alerts? You can unsubscribe any time. *

Yes

Yoga & Exercise

Have you done Yoga or Qigong before? What type? For how long?

Do you take regular exercise? What?

What do you hope to get from your Yoga/Qigong practice?

Which weekly class(es) are you most interested in?

General Health and Medical Conditions

Please give relevant details of any general health issues

Women's Health

The first four questions help keep all classes safe and relevant. The last two are particularly important for Well-Woman Yoga.

Do you suffer from any menstrual cycle or gynaecological pain or issues?

Yes

Are you pregnant?

Yes

Have you been pregnant in the past 3 years? If yes, have you done any post-natal yoga?

Yes

Are you breastfeeding?

Yes

Are you trying to conceive?

Yes

Are you menopausal or peri-menopausal?

Yes

Please give any additional details of any of the above or other issues here

Do you use an IUD? Are you on the Pill? Have you taken the Pill in the past? If yes, for how many years and when did you stop? (Another question for anyone signing up for Well-Woman Yoga)

Medications etc

Are you taking any medicine or natural remedies? Please give details? Do you suffer any side effects?

Have you consulted your GP before starting Yoga/Qigong? (in cases of health issues)

Yes

Some guidelines

PLEASE:

Try not to eat for at least 2 hours before class. If impossible, please eat lightly.
Wear comfortable clothes with socks you can remove (not tights).
I have Yoga mats and other equipment, but do feel free to bring your own Yoga mat if you wish.
Try to arrive 5-10 mins before class. If you are held up, please enter quietly.
Turn your mobile phone off before the class starts.

Declaration

I declare that the information I have given here is correct and that as far as I am aware I can participate in Yoga/Qigong classes without any adverse effects.
I understand it is my responsibility to inform my teacher of any injury or change in my health.
I understand that, should I have any concerns, I should consult the teacher before continuing, and my GP if required.
I understand that I should inform my teacher if I am uncomfortable or in pain during or after the class.
I am aware that hands-on adjustments may be made in class and give my consent.
I consent to Nurtureworks processing and storing (in accordance with
Privacy Policy) the personal health data that I have given above to help improve customer experience by keeping classes safe and relevant to student needs.

Please tick *

I confirm I agree with the above declaration

Payment

Select a single trial class or Unlimited 4-Week Trial offer: *

1 Class £12 GBP

4-week Unlimited Class Trial £35 GBP

Payment options *

Pay now with credit/debit card

Other (cash, cheque, bank transfer, none) Please indicate your preference:Other (cash, cheque, bank transfer, none) Please indicate your preference:

Credit/Debit card payment

Name on card

Credit Card number

Expiry date

If you have any trouble with credit card payment, please do contact Tiffany.