Today's Date

Name of Course

Course Fee 

Payment status:

Paid / Unpaid

Students are ultimately responsible for their own health and well being, but knowing a few details about you helps us to teach appropriately, lets us know when we may need to adapt practices and gives us a chance to introduce practices of particular benefit to you.

All information written on this form is kept in strictest confidence. It is important to let the yoga teacher know if any of the below changes during the yoga course.

Name

Phone 

Mobile 

Email

Address 

Date of Birth 

Has your child ever practised yoga before? If yes, when and for how long?

If possible say why your child is coming to yoga class. e.g. relaxation, increased flexibility, health, concentration etc.

Does your child have an emotional temperament which could affect the group situation, such as: mild autism, recent bereavement, learning disability etc. If so please give details.

Has your child recently had a physical injury or undergone surgery in the last two years? If so please give details.

Do you have any of the following? (Tick relevant conditions and give a brief history below):

Diabetes

Asthma

Epilepsy

Severe food allergy

Spinal problems or conditions

Attention deficit disorder

Autistic spectrum

Dyslexia

Dyspraxia

Learning difficulties

Hyperactivity

Eating disorders

Brief History

Does your child have permission to attend the yoga class/camp?

Does your child have permission to do outdoor activities in our garden?

Does your child have permission to do cooking/baking activities on Yoga Camps?

All information you give us will be treated in the strictest of confidence.