Spirited Health
HEALTH FORM AND QUESTIONNAIRE
It is important that you Answer the following questions truthfully. All information is held private. I am a Nurse and I only use this information so that I can bring you a yoga class that is safe for your body.
Name: ___________________________________________________ Date: _______________
Address: _________________________________________________________ M/F: ________
City: _______________________________ State: ______________ ZIP: ___________________
Home phone: ________________________ Cell phone: _________________________
Email: _____________________________________________
Birth Date: __________________
Name of class you are taking here today: ____________________________________________
How did you hear about me? _____________________________________________________
Do you have a diagnosis by a physician? If so, please explain: ________________________________________ __________________________________________________________________________________________
Are you taking any medications at this time? If so please explain: _____________________________________
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What type of exercise or physical activities so you participate in and how often? ________________________
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Do you have previous experience with Yoga? If so, please explain: ____________________________________________________________________________________________________________________________________________________________________________________
Do you have any medical condition which might prevent you from exercising or participating in physical activity? If so please explain: ____________________________________________________________________________________________________________________________________________________________________
Would you be interested in receiving email newsletters from Spirited Health that will include: positivity, Yoga tips, Life coaching hacks to make you think outside of the box, support and upcoming events and workshops? Y N
Would you be interested in a Life Coaching Session? Y N
Would you be interested in Energy work? Y N
Please provide an emergency contact:
Name: _________________________________ Phone number: _________________________
Why have you come to Yoga class? Please explain briefly: __________________________________________________________
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Spirited Health Policies & Procedures
Pricing: All drop-ins ( if allowed) are $15.00 to be paid the day of class. 6 week class series are to be paid in full prior to the first day of class and are $75. Cost for lectures or workshops will be as posted prior to presentation. No refunds are given after the first class. Any other service provided by Spirit Health i.e. Wellness coaching, Shamanic work and/or Energy Medicine, such as chakra balancing shall be discussed and assessed prior to an individual session.
Class Cancellations: Classes may be cancelled due to inclement weather. Student will be notified by either the instructor or the staff. Make up classes will be offered for class series at the end of the series, if the class is cancelled by either inclement weather or by the instructor. Classes may be dropped from the schedule due to limited attendance. We will make every effort to inform students of schedule changes.
Policy: there are no make-up classes or refunds given for student absences unless there are extenuating circumstances such as serious illness or accident. In such case credit for classes will be issued.
Agreement of Release and Waiver Liability
I, _____________________________________________ herby agree to the following:
1. That I am participating in the Yoga or Health Program or related workshop offered by Spirited Health during which I will receive information and instruction about Yoga and Health. I recognize that this requires physical exertion which may be strenuous and may cause physical injury and /or side effects from injury and I am fully aware of the risks and hazards involved.
2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any Yoga class, Health Program or related Workshop (collectively referred to as “Activity”). I represent and warrant that I am physically fit and that I have no medical condition which would prevent my full participation in any such Activity, and that I should continue to keep Spirited Health informed of any physical or other condition or disability which would prevent or limit my participation in any Activity.
3. In consideration of being permitted to participate in any Activity that I sign up for, I AGREE TO AND, I ASSUME FULL RESPONSIBILITY FOR ALL RISKS, INJURIES OR DAMAGES, KNOWN OR UNKNOWN, WHICH I MIGHT INCUR AS A RESULT OF PARTICIPATION IN ANY SUCH ACTIVITY.
4. In consideration of being permitted to participate in any Activity that I sign up for, I hereby fully and forever release and hold harmless Spirited Health, its employees, owners, and agents (collectively called “Releasees”) from and against any and all liability to me, my heirs, executors, personal representatives, administrators and /or their property, caused or alleged to be caused by any action or inaction of any of the Releasees. I hereby waive any right to sue any of the Releasees for any injury or damages I may incur whether known or unknown resulting from my participation in any Activity.
5. I understand that any images or photographs obtained by Spirited Health can and may be used to promote or advertise for Spirited Health and its services.
6. I understand and agree this document is to be binding on myself, my heirs, personal representatives, executors, administrators and assigns.
7. I AGREE TO DISCUSS ANY HEALTH RESTRICTIONS, QUESTIONS OR CONCERNS WITH THE INSTRUCTOR PRIOR TO ANY CLASS PROGRAM OR WORKSHOP IN WHICH I AM ENROLLED.
I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.
Date: ____________________ Signature of Participant: _________________________________________________
IF PARTICIPANT IS UNDER 18 YEARS OF AGE OLD:
As Parent or Legal Guardian of ___________________________________, I consent to the above terms and conditions.
Date: _____________________________ Signature of Parent of Legal Guardian: ________________________________