Intake Form Step 1 of 2 50% Date MM slash DD slash YYYY Name* First Last Email* Enter Email Confirm Email Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell*Please list any pre-existing physical injuries or ailments that may affect your ability to practice yoga.*Please list any medications you are taking and any specific places in the body you feel pain.*Any other conditions or concerns you would like the instructor to know?*How did you hear about VegaYoga & YogaToGo?* Have you taken yoga before? When? Where? What do you hope to gain from practicing yoga? Agreement of Release and Waiver of LiabilityBy signing the following, the practitioner is aware of the related risks of yoga/movement arts, and releases any and all financial responsibilities of the instructor and/or VegaYoga & Movement Arts, Inc. I agree to and understand the following:Please Check All Boxes* 1.Practicing the Asanas (postures) of yoga is a physical practice that involves stretching, strengthening and deep breathing. 2. Practitioners should consult their primary care doctor before beginning a physical practice or exercise routine. 3. By participating in this yoga/movement arts class I knowingly, voluntarily and expressively waive any claim I may have against VegaYoga & Movement Arts Inc. for injuries or damages sustained during yoga class. 4. I, my heirs, or legal representatives forever release, waive and agree not to sue VegaYoga & Movement Arts Inc. for any injuries that occur on our premises or before, during and after class. 5. I realize I need to be responsible and aware of my own physical limitations for practice. 6. I am aware that any physical practice may cause physical injury and I am aware of the hazards involved. 7. Additionally, I am aware of the great benefits a yoga/movement arts practice can bring into my life and that the instructor is a guide who will keep me as safe as possible. I also realize that no one knows my body better than myself. Today's Date* MM slash DD slash YYYY Initial* Initial first and last name This area will be used as your signature
