Registration Forms

Health Information: Adult (print, complete and bring with you)

Name _____________________________________________________________


City, State,  Zip _________________________________________________________

Home Phone ____________________Other phone (s)_________________________

Date of birth: _____________

E-mail if you would like updates: __________________________________________

Emergency contact (relationship and phone #): _______________________________

Male/Female    (circle one)                              Age ____      Are you Pregnant?________

Circle and clarify any conditions that apply to you:

Allergies _______________________________________________________________


Asthma ________________________________________________________________

Diabetes _____________________________________________________________

Disc Disease/ Osteoporosis ______________________________________________

Epilepsy _____________________________________________________________

Glaucoma ____________________________________________________________

Hernia ________________________________________________________________

Heart Conditions _____________________________________________________

Blood Pressure ______________________________________________________

Recent Injuries/Surgery _________________________________________________

Spinal Conditions ________________________________________________________

Describe your present state of health_______________________________________

Describe in detail and physical or mental conditions that would be helpful for your instructor to be aware of:

List any medications you are taking and the conditions you are taking them for (use back):

Do you have any questions relative to your full participation in class?


Lifespan Yoga™ Release and Waiver of Liability

I __________________________________(print name) hereby agree to the following:

  1. I am participating in yoga classes, health programs and/or workshops offered by Lifespan Yoga®. I will receive information and instruction about yoga and health. I realize that yoga includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, adjust the posture and ask for support from the teacher. I will continue to breathe smoothly.
  2. I understand it is my responsibility to consult with a physician prior to and regarding my participation in yoga classes, health programs and/or workshops. I represent and warrant that I am physically fit and I have no medical condition that would prevent my full participation in yoga classes, health programs and/or workshops. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions.
  3. In consideration of being permitted to participate in yoga classes, health programs and/or workshops, I assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the program.
  4. In further consideration of being permitted to participate in yoga classes, health programs and/or workshops, I knowingly, voluntarily, and expressly waive any claim I may have against Lifespan Yoga®  for injury or damages that I may sustain as a result of participating in the program
  5. My heirs, legal representatives forever release, and I waive, discharge and convenient not to sue Lifespan Yoga® for any injury or death caused by their negligence or other acts.

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above. I affirm that I alone am responsible to decide whether to practice yoga. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against Beth Daugherty or Lifespan Yoga®.

Signature of  Participant  _____________________________Date ______________________