YOGA INTAKE FORM

NAME: ______________________________________________________________________________

ADDRESS: ____________________________________________________________________________

PHONE: ________________________________________

EMAIL ADDRESS_______________________________

Have you practiced Yoga before? If so, what style and how long? ________________________________

Please list any injuries, medical issues, and/or important medical history:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Would you like to receive yoga related emails periodically from Jeanie Sallah (Howella)?

(Circle one)     YES   NO

Emergency Contact (name and number) _____________________________________________________________________________________

LIABILITY / STUDENT WAIVER AGREEMENT

(If under 18 years of age, this form must be signed by a parent or guardian)

I _______________________________________ (print name) understand that yoga includes physical movements as well as an opportunity for relaxation, stress management, and relief of muscular tension. As is the case with any physical activity, the risk of injury is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, adjust the posture and ask for support/modifications from the teacher. Throughout the practice I will continue to breathe smoothly and honor my body.

Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I affirm that I alone am responsible to decide whether to practice yoga. I hearby agree to irrevocably release and waive any claims that I have now or hereafter may have against Jeanie Sallah (Howella) and/or Yoga From A Natural. I am signing this agreement voluntarily and recognize that my signature serves as complete and unconditional release of all liability to the greatest extent allowed by law in the State of Florida.