Sign up - Meditation and Relaxation group

I consent to give the required information.

Yes

Name *

Phone number *

Email address *

Age *

Ethnicity *

1st part of postcode (EG- TS3, TS5, TS10) *

Emergency contact name *

Emergency contact number *

Do you get short of breath at rest or doing light activity? *

Yes
No

Has your doctor advised you not to participate in exercise? *

Yes
No

Do you lose your balance because of dizziness or do you ever lose consciousness (black out)? *

Yes
No

If you answered YES to any of the above please ask your GP/ health care professional before participating. By signing below you indicate you have permission to participate. If you have answered NO to all of the above please answer the following: *

OK

Do you have any long term health conditions or progressive conditions? If so, please note below. *

E.G. Heart Condition Respiratory Condition Diabetes High Blood Pressure Progressive illness (Cancer, HIV, Parkinson’s) Vision Impairment Hearing Impairment Mental Health Condition

Does you have any Muscular Skeletal Kinetic conditions? If so, please note below. *

E.G. Osteoarthritis Inflammatory Arthritis Fibromyalgia Trauma (tendonitis, broken bones, injury etc) Long term pain >3 months Other MSK condition

Does you have ny mental health diagnoses? If so please list below. *

Do you have any specific needs when attending class? (Wheelchair/walker access, medication incase of emergency etc). *

Do you drink alcohol, take recreational drugs or non prescribed medicines? If so please state below. *

Please note all participants must abstain from alcohol and substances 24 hours before class for the purpose of health and safety. If an individual attends class and appears inebriated we will unfortunately have to decline entry.

Will you have a carer supporting them in classes? (Carers are welcome to attend without charge). *

Yes
No

Please use this box if there is any additional information you would like us to know.

If you suffer from an illness or injury and are not sure whether you should practice these exercises: then please check with your doctor first. I hereby declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity or other illness that would prevent my participation in physical activities. I agree to assume the responsibility and accept all risks of injury. Aimee Louise Bell (Director of AMALAwellness and Teacher) ] will not be liable for any injury or harm you sustain from our Yoga program, our online information or our website. *

I have read and agree.

I have read, understood and completed this questionnaire honestly and agree to keep my instructor informed of any changes. I understand that I participate at my own risk. If you change your mind and wish to opt-out and withdraw your consent to share this information, please let your instructor know or contact AMALAwellness on info@amalateesside.com or 07774600440. (You are free to do so at any time). Please electronically sign below. (Name) *

Sign up – Meditation and Relaxation group

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