Intake Questionnaire 
Please answer the following confidential questions, electronically sign the liability waiver agreement, and return to me via email attachment before your first class to bonnie@yogawithbonnie.com. You can also print and hand in at the first class. THANK YOU.

Name______________________________________Age______Date____________

Email__________________________________________Best Phone #__________________________________

Which class(es) are you taking?_________________________________

How did you hear about the classes? Please X and answer as appropriate.

Friend(name?)_______________________Flier(from?)_____________________Websearch____Facebook____

Other-please note:___________________________________________________________________

Have you taken Yoga classes previously?  __Yes__No

If yes, where, when, with whom, what type, and level?

Why are you taking this class? Please X all that apply:

__To improve flexibility		                __To manage stress            _To get stronger
__To learn to meditate			__To breathe better
__To learn about Yoga			__To improve balance

__Other________________________________________________________________

Please describe any physical or medical concerns, recent challenges or limitations, or anything else the teacher should know (example: high blood pressure, osteoporosis, back, hip, knee, neck, shoulder, wrists, recent surgery, balance issue, etc).

Describe your current exercise and/or sports regimen, and how often. For example: non-existent, walk a few times per week, lift weights once per month, treadmill, etc.

Do you or have you tried meditation? __N___Y.  If yes, when and where?_________________________________

Please share anything else about yourself that will help the instructor get to know you better.

Liability Waiver Agreement
PLEASE PRINT YOUR NAME AND SIGN 

I _________________________________(first and last name) understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury is always present and cannot be entirely eliminated. 

If at any time during the class, you feel extreme discomfort or strain, gently come out of the posture, continuing to breathe smoothly. You may rest at any time during the class. It is important in yoga that you listen to your body, and respect its limits on any given day.

I, the undersigned, understand that Yoga is not a substitute for medical attention, examination, diagnosis or treatment. I should consult a physician prior to beginning any activity program, including yoga. I recognize that it is my responsibility to notify my teacher of any serious illness or injury before every yoga class. I will not perform any postures to the extent of strain or pain.

I accept that neither the instructor, Yoga with Bonnie, nor the hosting facility Yoga is Therapy is liable for any injury, or damages, person or property, resulting from the taking of the class. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against the instructor or the hosting facility.

________________________________ student signature
 
________________________________ date