New Student 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 QuestionsHave you ever experienced or currently have any of the following? Please tick all that apply. High or low blood pressure Diabetes Epilepsy Heart condition Glaucoma If you ticked yes to any of the above conditions please explain if/how they are currently affecting you.Do you have any other medical conditions that we need to be aware of?NoYesPlease explainWhat would you like to gain from this class?*Have you done yoga or pilates before?*NoYesNumber of years How did you hear about our classes?* Do you consent to photos being taken during the class and used for marketing purposes?* No, I do not consent Yes, I consent AGREEMENT OF RELEASE and WAIVER OF LIABILITYPlease read carefully before signing. As a student of this yoga and/or pilates class: ❖ I understand that there is a risk of injury associated with yoga and pilates 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 a yoga and pilates class for each individual person. Only my doctor 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. ❖ 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 PhoneThis field is for validation purposes and should be left unchanged.
