Pregnancy yoga registration

Which class are you interested in
Pregnancy Yoga Knutsford Mondays 19.00-20.15Pregnancy Yoga Knutsford Weds 12.00-1.15pmPregnancy Yoga MCR Thursdays 11.45-13.00Online Pregnancy YogaCouples Birth Preparation WorkshopOne to oneOther

Name

Town

Telephone

Mobile

Email

Occupation

Age

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?

What style?

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?

Which?

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

Previous difficulties/miscarriages?

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 following
Morning 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-person
By 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

Photography and Video - In-person classes
From 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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