Flex Yoga and Massage - mobile yoga and massage in Adelaide
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New Client form
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Name
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First
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Address
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Email
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Would you like to join our mailing list?
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Information will not be supplied to third parties. The purpose will be purely for notification of upcoming events or last minute cancellations. You can opt out at any time.
What is your age?
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16-18
18-25
26-35
36-50
Over 50
Prefer not to say
Any previous medical history that may affect your yoga practice?
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High or low blood pressure
Pregnancy/given birth within last 3 months
Spinal problems including neck
Osteoporosis
Diabetes
Asthma
Heart condition
Joint replacement
Allergies
Dizziness
No known issues
Epilepsy
Other
Eye problems
Medical clearance may be required before participating in an exercise program
If you have selected any of the above, or have had injuries or surgery in the past 3 months, please specify
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Have you ever participated in a yoga class before?
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Yes
No
If so, do you know what style?
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Hot yoga (including bikram)
Hatha
Iyengar
Ashtanga
Yin/Restorative
Vinyasa flow/Power yoga
Huh?? I didn't know there were different types!
What level practioner would you consider yourself to be?
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Complete beginner
Beginner
Irregular attendance, but have past experience
Regular attendance for more than 6-12 months
Experienced
Other
If 'other', please specify
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What type of exercise do you currently participate in, and how often?
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Are there any particular goals you would like to achieve?
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What type of yoga classes are you most interested in?
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Yoga workshops
Yoga series of classes (6-8 week prepaid block)
General yoga classes (casual attendance)
Vinyasa flow yoga (strength)
Restorative yoga (relax and stretch)
Meditation
Yoga for special groups (e.g. cyclists, runners)
None of the above
One on one or small group private classes ($60 + travel may apply)
More than one can be selected
What class times suit you best?
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Weekend mornings
Weekend afternoons
Weekday mornings (before 9am)
Weekday mornings (after 9am)
Evenings (after 6:30pm)
Late evenings (after 7:30pm)
How did you hear about this site?
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Internet Search
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Friend
Social media
Other
If Other please specify:
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Informed Consent
I agree that I am in proper physical condition to participate in yoga classes, workshops and other wellness, exercise and healing arts activities (collectively, "the Activities") offered by Flex Yoga and Massage and its instructors including independent contractors. I agree that I am over 18 years of age (or legal guardian will be required to sign paper based consent form before participating).
I have been informed and understand that strength, flexibility and cardiovascular exercise, including Yoga, are potentially hazardous activities. I also have been informed and understand that these activities involve a risk of injury and that I am voluntarily participating in these activities with full knowledge and appreciation of the dangers involved. I understand that I could experience muscle, back and other injuries during exercise. I understand my physical limitations and am sufficiently self aware to stop physical activity before I become ill or injured. I understand it is my continuing responsibility to disclose Flex Yoga and Massage of any previous medical conditions, injuries or surgeries prior to my first class and any changes to my medical condition.
I understand that Flex Yoga and Massage will not be held responsible for any neglect on my behalf to seek medical approval prior to commencing the Activities. I also understand that classes taught at Flex yoga and Massage are not meant to replace any form of medication or medical treatment that I am currently seeking now or in the future.
I understand that Flex Yoga and Massage may photograph or video classes or events and publish these materials on its Website or Social Media page. I hereby consent to the use of my image that may appear in such photograph or video unless otherwise informed.
I declare all of the information provided by me to be correct to my knowledge and have not withheld any information that may result in any consequences.
I agree to advise Deanne Kong from Flex Yoga and Massage in writing if any of the information provided by me changes.
I have read and understood the above Waiver of Release and Assumption of Liability
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Yes, I agree to the above
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