YOUR DETAILS

Full name*

Full Address (including postcode)*

Tel Number*

Email*

Emergency contact and number*

MEDICAL HISTORY & HEALTH ISSUES

If you have a serious medical condition, please consult with your doctor before attending.

Please list any relevant medical conditions (e.g. high or low blood pressure, arthritis, heart condition, joint problems), medication or allergies.

Have you had any operations or recent injuries? If yes, please give details and when.

Are you pregnant, trying or recently been pregnant?

Do you have any limitations in your physical activity level, or movements that cause you pain?

Please state any access needs or specific learning requirements, we will endeavour to support these.

YOGA AND FITNESS HISTORY

Have you done yoga before? If yes, what type, when and how often?

What other exercise or activities do you currently do? How often?

Do you have any concerns about attending? If so please provide details and we can arrange for you to have a chat with Deborah prior to the course starting.

As there will be refreshments available afterwards, any allergies or dietary requirements we need to know about?

What do you feel you will get out of this course? e.g. learning about yoga and how it can help me and/or my children, physical well-being, mental well-being, I need something for myself, etc

Photo Permissions

I give permission for Little Hiccups to take photographs and/or video of my child and/or family during sessions.
I grant Little Hiccups full rights to use the images resulting from the photography/video filming, and any reproductions or adaptations of the images for fundraising, publicity, or other purposes to help achieve the group’s aims. This might include (but is not limited to) the right to use them in printed and online publicity, social media, press releases, and funding applications.

You have the right to opt out at any time.

I am happy for photos and video of my child and/or family to be taken:

YesNo

YOGA PARTICIPATION AGREEMENT

1. Understanding and Responsibility:

Yoga postures (asanas) should be held comfortably. If a posture is too difficult or causes pain, you may stop and rest at any time during the class. It is important to listen to your body and respect its limits.
Yoga is not a substitute for medical attention, examination, diagnosis, or treatment. If you have any injury, sickness, or condition that may be affected by physical activity, consult with a physician before participating in yoga classes. Notify the instructor of any serious illness or injury before each class.

2. Waiver of Liability:

By participating in the yoga class, you voluntarily and expressly waive any claim against Deborah Grossman, the instructor, or the owner/leaser of the premises for any injury or damages sustained during the class.
Neither the instructor nor the hosting facility is liable for any injury or damages to person or property resulting from participation in the class.

3. Personal Responsibility:

You acknowledge the possible risk of injury from fitness activities and confirm that you are voluntarily participating. You take full responsibility for monitoring your physical condition and understand that participation is at your own risk. Inform the instructor immediately if you develop any condition that affects your ability to exercise or if there are any changes in your health or medical treatment, including injuries. Stop exercising if necessary. Act with due care to safeguard your own safety and that of fellow students.

4. Attendance and Communication:

To the best of your knowledge, you will be able to attend all sessions.

By submitting this form, you certify that the information provided is correct and agree to promptly communicate any future changes before the Yoga Assessment. Contact an instructor if you have any queries or concerns.

I accept the terms.

YesNo