Name *

First Name

Last Name

Are you affected by any of the following?

High Blood Pressure

Low Blood Pressure

Detached retina

Headache

Bone or joint problem

Carpal Tunnel Syndrome

Neck injury

Heart problems of any type

Asthma

Glaucoma

Diabetes

Arthritis

Chronic Pain

Back Injury

Knee Injury

We provide our students with newsletters and information about our classes and services. Do you wish to receive these (please circle)? Yes or No

Yes

No

DECLARATION *

Yoga and Meditation is founded on the development of self-awareness of his or her own physical and mental capabilities and limitations. It is essential that students retain full responsibility for their own physical well-being in applying instructions in the practice of yoga and/or meditation to their own circumstances, both during and outside classes. Soul Flame Yoga provides instructions to students in the practice of yoga and meditation strictly on that basis. Soul Flame Yoga will not accept liability for any injury or loss suffered by students in their practice, whether during or outside classes. I accept responsibility for informing Soul Flame Yoga about any medical conditions, injuries, pregnancy or changes to my health that may affect my practice, prior to a class commencing. I understand that I participate in yoga and meditation at my own risk and accept responsibility for any loss or injury suffered. By Selecting YES and Submitting, you agree to Soul Flame Yoga's terms and Conditions as set out above.

YES