Retreats Indemnity & Information Form

 
 

The following information will enable us to offer you the safest and most appropriate yoga postures for your current level of health.

All information given on this form will be treated as confidential.

Name *
Name
Date of Birth *
Date of Birth
Address
Address
This list is by no means comprehensive and you should consult with your physician if you suffer any other condition not listed.

Please let us know in the box below if you have any of the following, along with any relevant information:
  • Multiple sclerosis
  • Parkinson’s disease (or similar)
  • Meniere’s disease
  • Diabetes
  • Epilepsy or Seizure disorder
  • Dizziness
  • Surgery within the last 6 months
  • Mental illness
  • Fibromyositis
  • Disc disease
  • Carpal tunnel syndrome
  • Enlarged heart, heart valve problem or have suffered a heart attack in the past 2 years
  • Osteoporosis
  • Asthma
  • Chronic fatigue syndrome
  • Recurring headaches
  • Vertigo
  • Pregnancy
  • Hernia or ulcers
  • High or Low blood pressure
  • Severe arthritis of the spine
  • Hyperthyroid condition
Please let us know in the box below if you have or have ever had any of the following, please be specific and add any relevant information:
  • Cramps
  • Back pain/injury
  • Shoulder pain/injury
  • Wrist pain/injury
  • Neck pain/injury
  • Muscular pain
  • Knee pain/injury
  • Ankle pain/injury
  • Other
Do you smoke *
Are you taking any form of medication that may have some bearing on your yoga practice? *
Please read the following carefully and tick the box if you agree *

I understand that the instructions given throughout the classes are intended as guidance only. I understand that while all due care will be taken by the teacher, they cannot be held responsible for my improper practice at any time.

To ensure that no personal injury occurs, I agree to adjust my practice according to my limitations and the decision to perform any yoga postures remains mine. I declare that I will take full responsibility for myself during the classes.

I will notify my teacher before each class begins of any recent injury, illness, surgery or pregnancy.