Yogalates Registration Form Please complete and submit this form prior to your first class. Please enable JavaScript in your browser to complete this form. - Step 1 of 3What course or courses are you registering for?Beginners YogaGentle Yoga SeriesYogalatesYoga & Meditation SeriesFull Name *FirstLastEmail *Do you need to update your personal details in our system? *YesNoPlease tick Yes if you haven't been to our centre before.Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeEmergency Contact Details (name, relationship and phone)Where did you hear about us? *FacebookGoogleWord of mouthFamily or FriendI'm already a clientNextHealth HistoryPlease list any serious injuries such as: falls, head injuries, broken bones, dislocations, surgeries and any other serious medical conditions you have had in the past. *Please tick if any of these are relevant to you: *Fainting attack, blackouts, epilepsy / SeizuresHeart problems, chest pain or strokeHigh blood pressure, Blood clotsNeck/Spine injuryEpilepsy / SeizuresSurgery in the past 12 monthsMuscle joint or any injury that affects you (neck, shoulder, wrists, knees, ankles, etc)Any autoimmune diseasePregnancy now or within the last 3 monthsBack pain, shoulder pain, sciatica pain Cancer / TumorNone of the aboveFrom 1 to 10, what is the fitness level you consider yourself to be at: Fitness Level: 0 Anything else we need to know about your health?NextPrivacy PolicyInformation gained from this form will ensure you are provided with the best possible service. This information is kept confidential and will not be passed on without client's consent.Consent to Yoga *I acknowledge that I am a participant in this class. I understand that is my responsibility to participate to my level of physical, mental and emotional ability at all times.It is my responsibility to inform my practitioner of any illness, injury or medical condition that I may have currently, or have had in the past, that might affect my ability to participate.I release any facilitator of SA Wellness Centre of any liability in the event that I become injured, sick, disabled or die. All information provided on this consultation is presented for general, educational and informational purposes only and is not intended as substitute the advice provided by your GP.Submit
