Health Declaration

Please fill out the following form in order to participate in my yoga classes.

All information remains confidential

(see GDPR policy for further details on how your data is stored- this can be found on GDPR page of the website here)

YOUR HEALTH /CONTACT DETAILS

First Name

Last Name

Date of Birth

Hav you been diagnosed with any ofte following medical conditons, illnesses or injures? *

High blood pressure

Recent surgery in last 12 months

Asthma/COPD

Osteoarthritis

Diabetes

Lower back pain

Vertigo

heart attack/angina

Anxiety/Depression

Other health conditions (please list below)

Please list any other medical conditions you have or any current investigations you are having through your GP or hospital care

Are you pregnant or post partum?

Yes

How did you hear about my classes?

EMERGENCY NAME AND CONTACT

Please provide an emergency contact name

Please provide and emergency contact number

HEALTH WAIVER

I declare that the information provided is accurate & complete and I waive and release Ruth Murray, Energise Yoga from any injury, or damages, to person or property, resulting from the taking part in any online or face to face yoga classes. Please ensure you inform me of any changes to your health following submission of this form. Practice at your own pace and listen to your body during classes.

SOCIAL MEDIA CONSENT

I give my consent for photos to be taken in classes and understand they may be used for social media (Facebook, Instagram) to promote Energise Yoga

I DO NOT give my consent for photos that may be taken in classes to be used on socia media (Facebook, Instagram) to promote Energise Yoga

Thanks for submitting!

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