- Urban Shanti Community Studio Boscombe -
PLEASE PRINT AND FILL IN MEDICAL FORM AND LEGAL WAIVER AND BRING IT WITH YOU TO YOUR FIRST CLASS
URBAN SHANTI CLIENT INTAKE FORM – CONFIDENTIAL INFORMATION WELCOME
Annual/Monthly/DropIn Membership Paid Today’s Date: _______________
We would like to make your yoga/dance/healing/restorative/learning experience at Urban Shanti as effective and enjoyable as possible. If at any time you have questions regarding your session, please let us know.
Name _________________________________________ Date of birth _______________________
Address_____________________________City___________ County________ PostCode_________
Home Phone: ________________ Mob Phone: _______________ Work Phone: ________________ Email Address _____________________________________________________________________
Emergency Contact (name, #) ________________________________________________________
Referred by (Name, Flyer, Ad, website, etc.): ____________________________________________
Have you practiced yoga before? ____ No ____ Yes (date of last class/practice______________)
How often do you practice yoga? (circle one) DAILY/WEEKLY/OTHER________________________
Style(s) of yoga practiced most frequently: (circle all that apply)
Hatha, Ashtanga, Vinyasa Flow, Iyengar, Kundalini, Gentle Restorative Yin, Bikram Other:______________________________________________
What are your goals/expectations for your yoga/dance/meditation practice/other Urban Shanti class? What benefits are you looking for? (Please circle all that apply, and explain) Strength training/ Flexibility/ Balance/ Stress relief/ Address health concern/ Alternative therapy/ Improve fitness/ Weight management/ Increase well-being/ Injury rehabilitation/ Positive reinforcement Other/Explain:______________________________________________________________________ Personal Yoga Interests: (circle all that apply)
Asana (postures) Pranayama (breath work) Meditation Yoga Philosophy Eastern energy systems Other:_____________________________________________________________________________
LIFESTYLE & FITNESS
How do you rate your current level of activity? (circle one)
Sedentary/Very inactive/ Somewhat inactive/ Average/ Somewhat active/ Extremely active
On a scale-of 1-10,(1 is lowest, 10 is highest)how would you rate your level of stress?
1– 2– 3– 4– 5– 6– 7– 8– 9– 10 Would you like to explain?__________________________________
Please review this list and check those conditions that have affected your health either recently or in the past.
___broken/dislocated bones ___muscle strain/sprain ___arthritis___ burtsitis ___disc problems ___scoliosis___ back problems___osteoporosis
___diabetes type 1 or 2 ___high/low blood pressure ___insomnia ___anxiety/depression ___asthma, short breath ___numbness, tingling anywhere ___cancer (explain below)
___pregnancy (EDD______________) ___surgery
___heart conditions, chest pain
(*AIDS, fibromyalgia, chronic fatigue, lupus, etc.)
Are you currently taking any medications? ____Yes ____No If yes, please list names and reason for medications. __________________________________________________________________________________
If any of the information on this form needs to be detailed or if there is anything else to share, please do so:
PLEASE READ THE FOLLOWING INFORMATION AND SIGN BELOW:
We are delighted to have you as a student at Urban Shanti. The following information will help you get the most out of your classes and clarify our instructor/student relationship.
We believe that Yoga and the classes at Urban Shanti Community Studio are more than physical exercise. Our teachers aim is to provide transformative practices that integrate body, mind and emotional tensions to arrive at deeper levels of relaxation and awareness. All exercise programs involve a risk of injury. By choosing to participate in our classes, you voluntarily assume a certain risk of injury.
Self–awareness is fundamental to the practice of Yoga as well as our various classes. By attending any Urban Shanti class, I affirm that I am solely responsible for my health and well-being, as well as my decision to practice yoga, dance, meditation, fitness, programs of physical exercise and non physical. I agree to inform my yoga instructor/teacher of any activities or movements, which I feel could cause injury to myself. I understand that yoga/dance/fitness is not recommended and is not safe under certain medical conditions. I do not have any physical conditions or disability that would limit my participation or preclude an exercise program. Urban Shanti Community Studio and the instructors shall not be held liable for any injury, loss or damage to property and/or persons sustained during or as a result of participation in any Urban Shanti class. I agree to listen to my body and monitor myself during every class session.
Signature: __________________________________________ Date: _________________
Before participating in this or any other exercise program, individuals should consult with a physician. I, the undersigned, acknowledge that I have voluntarily chosen and requested to participate in the yoga/dance/trapeze, class, workshop, event, or activity sponsored by Urban Shanti Community Studio and/or Angelic Tones. ________
I am aware that participation in the yoga/dance/trapeze class, workshop, event, or activity may be hazardous. I acknowledge that a certain minimum level of physical health, strength, fitness, and flexibility will be required. I represent that I possess the level of health, strength, fitness, and flexibility necessary to participate in these activities. I understand and acknowledge that in the context of a yoga class teachers may physically adjust and correct the student and should I not wish this to happen, it is my responsibility to notify the teacher at the start of the class. I am voluntarily participating in these activities with knowledge of the risks of injury. I assume all responsibility and liability for any and all injuries I may sustain due to my participation in these activities. _______
In consideration for being permitted to participate in the yoga/dance/trapeze class, workshop, event, or activity, I agree that I, my heirs, assignees, guardians, and legal representatives will not make any claim against, sue, or attach the property of, any of the hosts, instructors, organisers, or participants in the yoga/dance/trapeze class, workshop, event, or activity including but not limited to Urban Shanti Community Studio or Angelic Tones for injury or damage resulting from my participation in such yoga/dance/trapeze class, workshop, event, or activity. I release all such hosts, instructors, organisers, and participants, their agents and heirs, from any and all actions, causes of action, lawsuits, claims, or demands that I, my assignees, heirs, guardians, and legal representatives now have or hereafter may have for any and all injury, illness, loss of or damage to property associated with my participation in the yoga/dance/trapeze class, workshop, event, or activity. I have carefully read this agreement and fully understand its contents. I am aware and agree that it is a complete release of liability for any injuries or damages I may sustain due to yoga/dance/trapeze workshops, equipment, events, and activities, with Urban Shanti Community Studio and/or Angelic Tones and all such hosts, instructors, organisers, and participants. _______
By entering in to this agreement, I agree to receive email notifications confirming information on my purchases, bookings, class reminders, pass expirations and cancellations.
We reserve the right to photograph or film during our classes and to use these images for our website and marketing purposes. By entering into this agreement I agree that it is my responsibility to make myself known should I not wish to be photographed or filmed.
We take your Privacy seriously. Personal information provided to Urban Shanti or Angelic Tones will only be used to manage bookings, and provide an overall beneficial experience. Your information will not be passed on to any parties outside . We may wish to contact you via email/phone/Facebook. I am happy to be informed of events or promotions: YES/NO
If the account is for a person under the age of 18, I confirm that the contact details given here are for someone over 18.
Full Name (please print clearly):_______________________________________________