New Student Questionnaire
NAME PHONE
ADDRESS (include zip) email:
Date of Birth
How did you hear about this yoga class?
Have you had or do you have any of the following?:
Auto accident glaucoma
Asthma high blood pressure
Arthritis hearing loss (which ear?)
Cancer low blood pressure
Diabetes menstrual pain/discomfort
Fall off horse or other mishap
Please say more about any of these you checked or anything else:
Please answer yes/no or “want to learn more” and add your own comments below:
I walk/swim/bicycle/run or practice yoga at least 3 times a week.
I avoid sugar and caffeine (notice I didn’t say “completely”)
I use journal writing as a stress management tool, or would like to learn more.
Have you taken yoga before? What would you like to get out of this class?
WAIVER: I am aware that yoga, like any physical activity, could result in injury. By my participation in yoga classes taught by Diana Woodall or her designate, I agree to take full responsibility for not exceeding my physical capacity and for any injury that might occur as a result of participation in class. I have fully informed the instructor of any current or previous medical condition/injury that may affect my participation. I hereby waive any claim I might have at any time against the instructor, Diana woodall, or anyone connected with the premises in any way, for any injury or loss that may occur.
signed________________________________________ date____________
refund policy: Refunds may be requested before the start of the second class of a session. After that, there will be no refunds, except in the case of unusual personal circumstance. If there is more than one weather-related cancellation, the instructor may offer a makeup class if she is able to do so.
NAME PHONE
ADDRESS (include zip) email:
Date of Birth
How did you hear about this yoga class?
Have you had or do you have any of the following?:
Auto accident glaucoma
Asthma high blood pressure
Arthritis hearing loss (which ear?)
Cancer low blood pressure
Diabetes menstrual pain/discomfort
Fall off horse or other mishap
Please say more about any of these you checked or anything else:
Please answer yes/no or “want to learn more” and add your own comments below:
I walk/swim/bicycle/run or practice yoga at least 3 times a week.
I avoid sugar and caffeine (notice I didn’t say “completely”)
I use journal writing as a stress management tool, or would like to learn more.
Have you taken yoga before? What would you like to get out of this class?
WAIVER: I am aware that yoga, like any physical activity, could result in injury. By my participation in yoga classes taught by Diana Woodall or her designate, I agree to take full responsibility for not exceeding my physical capacity and for any injury that might occur as a result of participation in class. I have fully informed the instructor of any current or previous medical condition/injury that may affect my participation. I hereby waive any claim I might have at any time against the instructor, Diana woodall, or anyone connected with the premises in any way, for any injury or loss that may occur.
signed________________________________________ date____________
refund policy: Refunds may be requested before the start of the second class of a session. After that, there will be no refunds, except in the case of unusual personal circumstance. If there is more than one weather-related cancellation, the instructor may offer a makeup class if she is able to do so.
