The Yoga Center, Inc. Health History/Waiver Form

NAME DATE

ADDRESS ZIP CODE

TELEPHONE# (home) (work or cell)

E-Mail ADDRESS

OCCUPATION AGE SEX Female Male

Please check any & all conditions that apply to you:

Please explain answers for all checked items:


Please check all health practitioners you are currently seeing:

Briefly explain the condition you are working on with the above practitioner:

Please list medications you are taking:

Have you practiced yoga before this class? YES NO

If so, what style do you mostly practice?

How did you find our about The Yoga Center? Please check all that apply:

Friend/Relative (Name)
(This person receives a FREE class for referring you to us!)

Statement of Understanding

I am physically sound to proceed with the instruction of Yoga. I declare myself to be responsible for my own health and safety while participating in class. I understand the importance of keeping my teachers infromed of any health concerns. I agree to release The Yoga Center, Inc. and any of its instructors from any liability in the event of an injury.