Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Occupation

How did you hear about Lilian Yoga?

Please check the activities that you have done

Yoga

Meditation

Dance

Running

If you've attended yoga classes, what did you like or dislike about them?

What are your 3 goals for your sessions?

Please check any existing or past conditions:

High blood pressure

Back/neck pain

Knee pain

Low blood pressure

Hip pain

Anxiety/depression

Glaucoma

Pregnancy (current)

Diabetes

Please list any other health concerns, injuries, surgeries, allergies or medical conditions.

Liability Waiver

In any physical activity, the risk of serious physical injury is possible. Yoga and other activity is no substitute for medical diagnosis and/or treatment. The student assumes the risk of yoga or other activity and releases Lilian Yoga from any liability claims. Members must cancel a booked class 24 hours or more prior to your class start time without any penalty. After 24 hours charges 100% of my hourly rate for late cancellations will be collected. Class cancellations can be submitted via email or by text. I understand that I am holding a spot for another student so reservations for this class are nonrefundable. If I am unable to attend I understand that I can transfer to a friend for that time slot.

I am participating in classes or workshops with Lilian Lee at Lilian Yoga. I am aware of the physical risks involved with exercise and understand it is my personal responsibility to consult with my doctor regarding my participation. I have no medical conditions that I am aware of, would which prevent me from taking the classes or workshops, and I assume responsibility for any risk or injury I may sustain as a result of my participation. I have read the above release and waiver of liability and understand its contents. I understand that it is my responsibility to find a pace that suits me. I agree to the terms and conditions stated above.

Signature

Date

YYYY

Thank you for submitting your form. Looking forward to meeting with you!