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Shakti Yoga Centre Indemnity Form – All Styles
Personal details:
Full Name:
Mobile no:
Phone no (h):
Email:
Occupation
ID Number:
Have you practised yoga previously?
Yes
No
Period and Style:
Medical details (strictly in confidence):
Injuries and operations
Yes
No
Physical limitations e.g. Lower back problems, knees, neck, etc:
Yes
No
Please list all:
Are you currently on any medication?
Yes
No
Allergies:
Yes
No
Physical conditions e.g. High blood pressure, low blood pressure, heart conditions, etc:
Yes
No
Please list all:
Stomach or gastric problems:
Yes
No
Please list all:
Mental conditions e.g. Stress, depression, anxiety, etc :
Yes
No
Please list all:
General physical condition:
Please state any other health problems:
Which benefits are the most important to you? E.g. relaxation, physical exercise, improved health, meditation (focus). Please list all in order of importance:
Women only: (Please select appropriate response)
Menstruation:
Regular
Irregular
Backache during menstruation:
Yes
No
Discomfort experienced before / during menstruation:
Yes
No
Are you currently pregnant:
Yes
No
I recognise and agree that I will use my personal judgement to ensure that I do not unduly strain my body or cause personal injury. I agree and acknowledge that by signing this form, I indemnify and hold harmless Taryn Elise Herselman, and any other trained teacher or member for any injury sustained in any manner whatsoever. I further acknowledge that I enter the premises at 6 Oak Avenue, Norscot Slopes Security Village, Fourways where classes are given at my own risk and do not hold Taryn Elise Herselman responsible for any loss or damage to myself or my property that may occur in any way.
Date
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