Name

First Name

Last Name

Date

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Would you like to receive our newsletter?

Once a month max, we don't sell email addresses or spam.

yes

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

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Emergency Contact Relationship

Do you have any physical limitations that may require modifications in your process?

yes

If yes, please explain.

Are you currently taking medications (Rx or over the counter)?

yes

If yes to either, please list.

If any of the above need to be detailed, please describe.

For post-partum depression, please list date(s) of pregnancy.

Do you have any sensitivities to:

Medications

Foods (nuts, etc.)

Seasonal pollen

Fragrances

Other

If yes, please describe:

Please list any additional comments you would like to share:

Please read the following information and sign below: 1. I understand that yoga and yoga therapy can be relaxing and reduces muscular tension, but it is not a substitute for medical examination, diagnosis and/or treatment. 2. Any sexual remarks or advances to the teacher or a student in class will terminate the session and I will be liable for payment of the scheduled class. 3. Being that yoga should not be done under certain medical conditions, I affirm that I have answered all questions pertaining to medical conditions truthfully, and have checked with my healthcare practitioner to confirm that Yoga is recommended for any condition I have.

Client signature

By typing first and last name, Client agrees that form is considered signed.

First Name

Last Name

Date

YYYY

Student Teacher Liability Agreement

I, the undersigned, understand that yoga as a practice, and yoga teacher training includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I acknowledge that yoga is an exploration of a person’s physical and mental potential, and that my participation in yoga class can cause potential death, serious injury, or property damage. If I experience any pain or discomfort, I will listen to my body, adjust the posture and ask for support from the teacher. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. Please check with your healthcare provider to see if Yoga and Yoga teacher training is right for you. With a full understanding of the potential risks, I hereby assume the risks of participating in a yoga class, training sessions, and all that the Stacie Joy Yoga training entails. I affirm that I alone am responsible to decide whether to participate in any of the suggested practices. I hereby agree to irrevocably waive, release and discharge any claims and/or liabilities for death or personal injury or damages of any kind, except that which is the result of gross negligence and/or wanton misconduct of the persons or entities listed below, that I have now or hereafter may have against the following persons or entities: Stacie Jeanjaquet, and the officers, directors, employees, representatives, and agents of any of the above. I agree to not sue any of the persons or entities listed above for any of the claims or liabilities that I have waived, released or discharged herein. I indemnify and hold harmless the persons or entities mentioned above from any claims made or liabilities assessed against them as a result of my actions.

Type First and Last Name of Parent/Legally-Appointed Guardian (If participant is a minor under 18 years of age)

Minor's Birthdate

YYYY