BREATHE 

Section I: Personal Information

Name:__________________________________________________________

DOB:_______________Address_____________________________________

City:_________________________________State:_______Zip Code:______

Email:_________________________________Phone:__________________

Name/Phone of Emergency Contact:________________________________

Section II: Risk Assessment

Heart Disease YES NO

Shortness of Breath or Chest Pain YES NO Inhaler? (If yes, please bring it to every class)

High Blood Pressure YES NO

High Cholesterol Level YES NO

Significant Bone/Joint/Muscle Pain YES NO

Back Pain YES NO

Tobacco Use YES NO

Diabetes YES NO

Other, Please explain:_________________________________________________________

Are you active? YES NO

Activity or Exercise _____________________________________

Times per week _____________________________________

Are you currently taking any medication(s)? Yes No Type:______________________

SECTION III: AGREEMENT

IT IS YOUR RESPONSIBILITY TO INFORM THE INSTRUCTOR OF YOUR LIMITATIONS BEFORE CLASS BEGINS

I represent and warrant that I am in good physical health and do not suffer from any medical conditions which would limit my participation in the classes offered at BREATHE. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any of the yoga classes, programs, retreats, or workshops. I understand the risks associated with activities offered by BREATHE and I agree to follow all instructions so that I may safely participate in classes, workshops, retreats, or other activities. I hereby WAIVE AND RELEASE BREATHE, its owners, officers, employees, and instructors from any claim, demand, cause of action of any kind resulting from or related to my participation in the programs offered at the facility. In taking part in the yoga classes, workshops, retreats, or other activities at BREATHE, I understand and acknowledge that I am fully responsible for any and all risks, injuries, or damages, known or unknown, which might occur as a result of my participation in the classes, workshops, retreats, or other activities.

I have read the above release and wavier of liability and fully understand its content. I am legally competent to sign and voluntarily agree to the terms and conditions stated above.

Please practice mindfully and enjoy the many benefits of practicing yoga with BREATHE

Print Name:_________________________________________________________________

Signature:_________________________________Date:_____________________________

If participant is under 18:

As Parent or Legal Guardian of___________________________________,I consent to the above terms and conditions.

Print Name:_________________________________________________________________

Signature:_________________________________Date:_____________________________

Credit Card Information

BREATHE: A Family Yoga Center

Date:________Name:_____________________________________________________

Parent/Legal Guardian if patient is a minor:____________________________________

Address:________________________________________________________________

City:_________________________State:___________________Zip Code:__________

Email:_________________________________________________________________

Cell Phone#:____________________________________________________________

Name on Credit Card:_____________________________________________________

CC#___________________________________________________________________

Expires:________________________CID:____________________________________

How would you prefer to receive an invoice: Email______Text_______Both_____

Your CC will be stored on file with BREATHE for future CC transactions until we are notified in writing to deactivate the above CC information. I give permission to keep this information on file and to charge my credit card as needed for services rendered, until notified in writing that I want this information destroyed and no longer used for services with BREATHE.

Signature:______________________________________________________________Thank you for your business.

There is a 3% surcharge for all CC transactions.