Which class are you interested inPregnancy Yoga Tuesdays 19.00-20.15Pregnancy Yoga Thursdays 11.30-12.45Couples Birth Preparation WorkshopOne to oneOther
Due date & planned place of birth
Have you chosen to give birth at home?YesNo
Have you done Yoga before?YesNo
If yes, how long have you been practising for?
Have you ever practiced Pilates?YesNo
Before you were pregnant, did you do any sport or type of exercise?YesNo
If yes which
Are you currently doing any sport or type of exercise?
Why have you come to Yoga and what do you hope to gain from it?
Is this your first pregnancy?YesNo
If no, please give age of children
Do you smoke?YesNo
Are you currently taking any form of medication?YesNo
If yes, please give details
During this pregnancy, have you experienced any of the followingMorning sicknessHeadachesDizzinessSleep DisturbancesConstipationHeartburnBreathlessnessAnxietyPTSDNosebleedsAnaemiaDiabetesDepressionLower Back PainSciaticaAching GroinsPelvic Girdle PainVaricose VeinsOedema (swollen joints)High Blood PressurePre-Eclampsia
Please give details of any of the above you have ticked and/or other health issues you may encounter
Have you suffered any injury or undergone any surgery (i.e. cesarean section, knee surgery, etc) which might affect your Yoga practice? If so, please give details
Do you have any allergies or dietary requirements:YesNo
If yes, what kind
How did you hear about the class?
Would you like to keep in touch with Marylines news of classes, workshops, audio and video material. If yes, we'll add you to our mailing list. Your details won't be shared with anyone else.YesNo
Responsibility for my health - Online and In-personBy ticking this box I declare that as far as I am aware, I have disclosed to Yoga with Maryline all information regarding my health relevant to the practice of yoga and/or meditation. I take full responsibility over the health of myself in the yoga sessions (face-to-face or online) and for all applications of yoga I may practice outside the classes both now and in the future. I understand that any uses to which the recommendations, ideas and techniques are put are at my sole discretion and risk. Should there be any medical changes I will consult my doctor and inform Maryline as my yoga teacher
Covid 19 - In-person classesBy ticking this box I declare that I have read, understood and agree to abide by YogaSpirits Covid-19 policy and any updates as advised (link in website footer) I confirm that I attend classes entirely at my own risk and I hereby release, waive, discharge Yoga with Maryline from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me related to COVID-19 while participating in any Yoga with Maryline activity that may lead to unintentional exposure or harm due to COVID-19.
Photography and Video - In-person classesFrom time to time photographs and video footage of classes may be taken for use in my marketing. No compensation or fee may be claimed for this usage, and permission is always asked at the time.
Yes by ticking this box I consent to photos of myself (and where applicable my baby) being used in films and photographs in any and all media, now or at any time in the future.No by ticking this box I do not consent to photos of myself (and where applicable my baby) being used in films and photographs in any and all media, now or at any time in the future
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