Women's Circle Registration Form • NurtureWorks Yoga

Personal Details

First name *

Surname *

Date of Birth *

Email *

Address

City/Town

County

Postcode

Phone

Doctor's name & address

Doctor's phone number

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

No

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 this class?

General Health and Medical Conditions

Please give relevant details of any general health issues

Reproductive Health

Do you suffer from any menstrual cycle difficulties, pain or irregularities?

Yes

No

If yes please give details

Are you trying to conceive?

Yes

No

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

Yes

No

Are you breastfeeding?

Yes

No

Are you peri-menopausal or post-menopausal?

Yes

No

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

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?

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

No

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) to class.
Bring a large towel/light blanket to Yoga, if possible.
I have Yoga mats and other equipment, but feel free to bring your own mat if you would prefer.
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.

Signature

Clear