Pregnancy Yoga Registration Form 1Your Details2Emergency Contact Details3Health Questions4Waiver of Liability Your DetailsName* First Last Email* Phone*Date of Birth* DD slash MM slash YYYY Address* Street Address City State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact DetailsName* First Last Phone*Relationship* Health QuestionsCurrent Week of Pregnancy* Expected Due Date* Number of Vaginal Births* Number of C-Sections* Number of children and ages* Doctor/Midwife Name* Anticipated Place of Birth* Have you discussed doing physical activity during your pregnancy with your doctor?*NoYesDid your doctor set any parameters to your physical activity?*NoYesPlease explain*Have you done yoga or pilates before?*NoYesNumber of years* Have you ever experienced: or do you have any of the following (Tick all that apply) High Blood Pressure Low Blood Pressure/fainting Arthritis Diabetes Epilepsy Placenta Previa? Full or Partial? Heart Condition Diastasis Recti (abdominal separation) Varicose Veins / Hemorrhoids Pre-eclampsia Pelvic Girdle Pain Other high risk diagnosis If you ticked any of the above conditions please if explain if/how they are affecting you during this pregnancy.Do you have any other physical limitations I should know about?Do you have any issues, fears or phobias associated with this pregnancy or birth in general?What would you like to gain from these classes?How did you hear about our prenatal classes?* Do you consent to photos being taken and used for marketing purposes?* Yes No AGREEMENT OF RELEASE and WAIVER OF LIABILITYPlease read carefully before signing. As a student of this prenatal yoga and or pilates class: ❖ I understand that there is a risk of injury associated with yoga and pilates as with any physical activity in pregnancy. ❖ I am fully responsible for the outcome of my yoga practice and participation in this class. ❖ I understand that Shine Yoga, Kristy Graham and all teachers, substitutes, employees, and affiliates can not make a determination about the safety of prenatal yoga classes for each individual woman and her unborn child. Only my doctor/midwife can only make such a determination. ❖ I understand that if I move with care, intelligence, safety and self-awareness, injury is unlikely. Should injury occur or complications arise, Shine Yoga, all teachers, substitutes, employees, and affiliates are absolved of all responsibility. ❖ I understand that I should report any problems with my pregnancy to my doctor/midwife. ❖ I am having a healthy pregnancy. ❖ I am under a doctor/midwife’s care and have his or her consent to participate in this prenatal yoga program. ❖If I am experiencing any vaginal bleeding I will avoid yoga until the bleeding ceases. ❖ I will keep my yoga teacher informed with any changes in my pregnancy or physical health. I FURTHER STATE THAT I HAVE CAREFULLY READ THE FOREGOING RELEASE AND ITS CONTENTS. I FULLY AGREE WITH IT AND UNDERSTAND IT. Agree to Terms* I agree to the above conditions Printed Name* Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
