Pre-Enrolment

All NEW students are encouraged to fill out an enrolment questionnaire and are required to sign a legal waiver & release form, either online or in-person prior to class. Although the greatest care is taken to provide a safe and nurturing experience, I must confirm your acknowledgement of complete self-responsibility when attending my classes.

Please scroll below if you wish to read & sign this document online. Thankyou!

ENROLMENT QUESTIONNAIRE & LEGAL WAIVER

*If you only wish to sign the waiver required for class, please skip the questionnare and simply read/sign at the end of this document.

please complete the following questions to the best of your ability:

This information is to enable me to best support you in your yoga practice and in the very unlikely case of an emergency. Thank you.

* required

PLEASE NOTE THAT ALL INFORMATION PROVIDED IS KEPT PRIVATE AND CONFIDENTIAL

First name

Last name

Date of Birth

Phone

Address

Emergency Contact - Name & Phone Number

Past Yoga Experience

Please list history and approximate dates of surgery, major illnesses, chronic conditions, accidents, injuries or mental illnesses you've had or are currently experiencing (that may impact your yoga practice):

If you have suffered any of the above and are currently under the care of a healthcare practitioner have you gained approval from them to attend yoga?

Please describe any pain and or discomfort you may be currently experiencing in your body

Do you suffer from any of the following medical conditions or ailments?

neck / back pain / problems or other functional sensitivities/disabilities

diabetes / high or low blood pressure

asthma / breathing difficulties

epilepsy / sensory sensitivities or disabilities

If so, Please provide details:

Are you pregnant?

Yes

What is your primary reason for taking these classes? What benefits are you looking to recieve?

LEGAL WAIVER AND RELEASE, TERMS & CONDITIONS:

It is important whilst practising yoga that you listen to your body and respect your limits. If at any time during the class you feel pain, discomfort or strain, gently come out of the posture, rest, and request assistance if required.

Those under the age of 18 years, must have this form signed by a parent or guardian, unless declared legally independent and responsible for their own decisions. I understand that yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. By signing, I affirm that, if required, a licensed physician has verified my good health and physical condition to participate in this class. I will make Rick Lake aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician's approval to participate. I also affirm that I alone am responsible to decide to participate in yoga classes and to practise yoga and participation within this class is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Rick Lake, Yoga with Rick Lake and all related facilities and premises for any personal injury or negligence. Additionally, the facility and premise from which this class operates, are not in any way responsible for any loss or damage of my personal property. If any portion or this release from liability shall be deemed by a court of competent jurisdiction to be invalid, then the remainder from this release from liability shall remain in full force and effect and the offending provision or provisions severed here from. I have carefully read and completely understand and agree to the above terms of this liability waiver and release agreement. I duly sign this agreement voluntarily and recognise that my signature serves as complete and unconditional release of all liability to the greatest extent allowed by law and that it cannot be changed orally.

*I declare that I have read and agree to the terms & conditions above and that the info I’ve provided is accurate & complete

Printed Name:

Your Signature

Legal Parant or Guardian Signature (If required)

Form Submission Successful

THANK YOU FOR YOUR COURAGE TO EXPERIENCE THE INWARD JOURNEY OF KUNDALINI YOGA FOR HEALTH AND VITALITY.

I OFFER MY DEEPEST WELCOMING GRATITUDES AND LOOK FORWARD TO SHARING THIS DIVINE PRACTICE WITH YOU

Certified Kundalini Yoga Teacher

Rick Lake (Meher Bhagat Singh)

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