Mums & Bubs 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 QuestionsName and age of baby/toddler you will be bringing to class?* Do you have any other children? Ages?* Name of Dr/OB or Midwife* Name of Physiotherapist (if you have one), and have you been fully assessed post birth?* Have you discussed doing physical activity since giving birth with your doctor?*NoYesDid your doctor set any parameters to your physical activity?*NoYesIf yes, please explain*Have you done yoga and/or pilates before?*NoYesNumber of years* Are you currently experiencing any of the following symtoms? Please tick all that apply and give details below. Pelvic Floor/Bladder control issues Diastatic Recti Wrist pain or Carpal Tunnel Syndrome Varicose Veins / Hemorrhoids Recent C-section Depression/Post Natal Depression/Anxiety Breastfeeding concerns/Mastitis Allergies, for you and/or your child Other high risk diagnosis If you answered 'yes' to any of the above please give details of if/how they are currently affecting you.Do you have any other physical limitations I should know about?Do you have any issues, fears or phobias associated with motherhood?What would you like to gain from these classes?How did you hear about our Mums and Bubs Yoga Program? Do you consent to photos being taken of you and your baby and used for marketing purposes?* Yes, I consent. No, I do not consent. AGREEMENT OF RELEASE and WAIVER OF LIABILITYPlease read carefully before signing. As a student of this Mums and Bubs yoga and or pilates class: ❖ I understand that there is a risk of injury associated with yoga as with any physical activity. ❖ 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 Mums and Bubs yoga and/or pilates classes for each individual woman and her 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 health to my doctor/midwife. ❖ I do not have any postpartum contraindications to exercise. ❖ I am under a doctor/midwife’s care and have his or her consent to participate in this Mums and Bubs 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 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.
