HealthQuestionnaire

Name

First Name

Last Name

Date of birth

Full address (house/unit no., street, town/city, postal code, state, country)

Phone

Occupation

Emergency contact name & phone:

If you ticked any of the above boxes, or there are any other injuries, medications or health issues that we should know of, please specify below:

Are you pregnant?

Yes

If pregnant, any complications? Tick the box if yes.

Please read the following and click 'Submit' below if you agree to these terms and conditions. For insurance and legal reasons, we will be unable to commence your training before you agree to these terms.

I, the undersigned, will commence my classes under the following conditions: I know of no reason why I cannot study or participate in the activities and classes offered by Omni Yoga & Mindfulness. I agree to follow the facilitator’s/activity leader’s instructions both in the classes and outside.

I understand that the practice of yoga, mindfulness, meditation and sound healing may result in accident or injury. I release from any liability or loss sustained while training, studying, practising or in the application of yoga, mindfulness, meditation or sound healing: Omni Yoga & Mindfulness, the activity leaders and facilitators who give classes through Omni Yoga & Mindfulness (including guest facilitators and activity leaders), all other participants and students at Omni Yoga & Mindfulness.

I understand that Omni Yoga & Mindfulness recommends that mature students or students with a pre-existing illness, injury or condition should seek medical advice before beginning practice, training or exercise program and should have their health practitioner monitor that condition as necessary throughout the entire training program. I will not hold Omni Yoga & Mindfulness or its facilitators, activity leaders, participants or students responsible for doing this.

In the event of an emergency, I hereby authorise any licensed medical personnel to perform any accepted medical procedure deemed necessary. I agree to bear all the expenses of any such treatment.

I understand that all Omni Yoga & Mindfulness fees are non-refundable and non-transferable regardless of class attendance, unless otherwise stated.

I understand that Omni Yoga & Mindfulness reserves the right to change class times and/or facilitators/activity leaders at any time without notice.

I agree that Omni Yoga & Mindfulness may take photos and short videos of student/participant classes and that these materials may be used for display in promotional material of Omni Yoga & Mindfulness.

Yes

We'd like to send you periodically Omni Yoga & Mindfulness newsletters and offers. Please tick below if you prefer not to receive them:

No thanks

BY CLICKING 'SUBMIT' BELOW, I DECLARE TO HAVE READ, UNDERSTOOD AND AGREED THE ABOVE TERMS AND CONDITIONS, INCLUDING THE FULL TERMS AND CONDITIONS AVAILABLE ON THE WEBSITE OF OMNI YOGA & MINDFULNESS (www.omniym.com.au/terms-conditions).

Thank you! Your health questionnaire and agreement have been received.

Health Questionnaire