Healing Arts Yoga Registration Form

(Please Print) Name ________________________________________________

Address ______________________________________________

City ___________________________ State____________ Zip Code_________

Phone # ____________________ Work_________________ Cell__________

E-mail ____________________________________________________Age_______

Heath History:

1. Emergency Contact: ________________________________ Phone #______________________________________

2. Precautions; there are some medical restrictions. Please advise your teacher before class of any significant health problems, or if you are pregnant or presently menstruating. Adaptations can be made. If in doubt about your present physical condition, consult your health care provider before taking this or any exercise program.

a. Are you under a doctors care?_______if yes briefly explain, _______________________

b. Are You on any medication? ___ if yes, for what? __________________________

c. What is your previous experience with yoga?________________________________________

d. Do you have an injury that continues to give you problems?______

e.If yes, briefly describe:______________________________________________________________________

Is there anything; travel, physical conditin, etc that would affect your full participation in this class? If so, please explain __________________________________________

f. How did you hear about us? __________________________________________

g.. Tell us what you do for a living? ______________________________________________________________________________

h. What do you want to learn from this class_________________________________________________

Waiver: I understand the activity I am planning to undertake is entirely voluntary.

I release Patrick Weseman, The Healing Arts and all instructors and The Wellness Center from any liability in the event of injury. I understand it is solely my responsibility to discuss any prior existing health conditions. It is my responsibility to discuss exercise with my physician.

Signature___________________________________________ Date_____________________

Patrick Weseman 763-544-0644 or Cell 612 -508-1931