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Kia Yoga Registration Form

Name

First Name

Last Name

Date of Birth

YYYY

Phone Number

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you ever practised yoga?

How did you hear about Kia Yoga?

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

a) Have you ever been diagnosed with a heart condition?

b) Do you have diabetes?

c) Do you suffer from epilepsy?

d) Have you ever been diagnosed with high blood pressure?

e) Do you have any back problems?

f) Do you have any knee problems?

Women only (for questions g & h):

g) Are you pregnant?

h) Have you given birth in the last 3 months?

Any serious injuries, surgeries, or illness and conditions? Please include below:

What are you hoping to achieve from my classes?

T&C In the consideration of and as inducement to enrolling as a student I consent to the following: a) I have been examined by a qualified medical doctor within the last 6 months and have found by such doctor to be in good physical health and fully able to perform all yoga exercise which I am to learn and perform during my enrolment you. b) If I have been found to suffer from high blood pressure, heart disease or any known contraindication, I have submitted a letter from my doctor given consent to take part in the class. c) I will faithfully follow all instructions given to me by you and your instructors as to when, where and how to perform and not perform the yoga exercise. It being understood any deviation by me from such instructors shall be at my own risk d) I will not hold the property, instructors or employees responsible for any injuries, damage or losses that may occur at the property where yoga is taught. e) I will not hold the property, instructors or employees responsible for any injuries, damage or losses suffered by me whilst practising yoga with them. f) I consent to photos being taken of me and the use of all photographs of me to be used for promotional materials. I hereby waive my right to any royalty or any other compensation with regard to the usage of the photos. g) I understand that the tuition paid herewith and any such registration fees paid hereafter are non-refundable, any refundable are entirely at the discretion of Kia Yoga. h) I agree to follow the rules and etiquette as outlined by the instructor whilst in class and on the property where such a class is being held. Kia Yoga can terminate a membership at any time. i) Cancellations will be charged at full rate if for a class less than 1 hours’ notice is given and the space cannot be filled or for a private session less than 24 hours’ notice is given and the space cannot be filled.

I have read and consent to the T&Cs listed above.

Today's Date

YYYY