|
* Required Fields |
* NAME of Workshop or Class
:
e.g. Yoga for 50+ Beginner |
|
* DAY and TIME of Class:
e.g. Tuesday, 9:00 am |
|
* START DATE of Class:
e.g. April 7 |
|
| * Your Last Name: |
|
| * Your First Name: |
|
| Address: |
|
| City: |
|
| Postal
Code: |
|
| Home
Phone: |
|
| Work
Phone: |
|
| Do
you have Voicemail? If Yes, on which number? |
|
| Birth Date: |
|
| Occupation (optional): |
|
| * Your e-mail Address (needed for contact purposes): |
|
| |
| * Emergency
contact, if ever necessary |
|
| For first time registrations only: |
| Where
did you hear about this class? |
|
| What previous experience do you have in this program area? |
|
| For everyone (PLEASE remind us EVEN if you’ve registered before): |
| Do you have, or have you had, any medical conditions, health history concerns or joint problems? Please specify. |
|
| Are you currently or have you recently consulted with a health care professional for any other reason, including pregnancy? If yes, who and for what? |
|
| What would you like to get out of this session? Name several goals or interests if you like. |
|
| For Yoga for Pregnancy registrations only: |
| What is your due date? |
|
| What week of your pregnancy are you in? |
|
| Is this your first pregnancy? |
Yes
No |
Are you doing, or have you done any yoga, exercise, or other “preparation for pregnancy” types of activities?
Please specify. |
|
| What resources or other supports are you using to help you with this pregnancy? |
|
| Are there any medical, health history, or other concerns you have regarding your pregnancy which you have not already mentioned? Be specific. |
|
| Please choose your top three priorities for the class: |
connecting with your baby
easing aches and pains
learning relaxation techniques
learning pain control techniques
preparing physically for labour
preparing mentally/emotionally for labour
talking with other women
learning about yoga
time out for me
Other: Please specify
|
For YogaBaby registrations only: |
| What is your child’s name? |
|
| How old is your child? |
|
| What is your child's Birth Date? |
|
For babies and toddlers, what is his or her level of mobility?
(e.g. sitting, attempting to stand, crawling) |
|
| Is your child participating in any other recreational activities? |
|
| Does your child have any medical, health history, developmental, behavioural, or other concerns which may affect his or her participation in the class? Please be specific. |
|
For everyone - Acceptance of Personal Responsibility: |
Depending on each participant’s unique circumstances, not all movements or postures are appropriate for everyone. Each student is responsible for indicating any new or existing conditions to the instructor, judging and adapting to their own level of ability, never forcing any movement or position beyond their comfort level (no pain!) and assuming all risk associated with participation in this activity. Students with any medical conditions or joint problems must consult their physicians before beginning this activity.
|
|
BEFORE YOU CLICK ON THE SUBMIT BUTTON BELOW...
1. Please be sure you have filled in all * Required fields.
2. After you click "Submit Form to Lifesong Yoga" you will receive a "Thank you!" message confirming that your registration has succeeded.
3. If you DO NOT RECEIVE a "Thank You!" message, your attempt to register has not succeeded and you will be taken to the top of this form where you will find an "Error" message, reminding you to go BACK one step (click the "Back" button on your computer) and fill in all * Required fields.
|
|
|
