Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial Classes
This questionnaire has been designed to help you to enjoy your session safely. All information given will remain private and confidential.
Name Address Your email Telephone number Date of Birth Occupation Gender
Please tick if you would like to be on the mailing list for workshops, retreats and classes? Yes please Have you practiced yoga or Trapeze and Aerial Yoga before? YesNo If yes, please elaborate: for example, how much, how often, how long ago, what kind(s) of yoga have you done?
If no, what other type of exercise do you do? YesNo Are you a newcomer to exercise? YesNo
Have you needed to see a doctor or other health professional in the last 12 months YesNo If ‘yes’ please give further details: Are you currently taking any prescribed medication? YesNo If ‘yes’ please give further details: YesNo Have you any history of heart trouble? YesNo If ‘yes’ please give further details: Have you suffered from any serious illness/surgery in the last 6 months? YesNo If ‘yes’ please give further details: Are you suffering or have you in the last 5 years suffered from any of the following? Back, neck or shoulder painHip or knees painOther pain or injury to any jointsHead-ache / migraineHigh blood pressure, hypertensionCirculatory disturbance, e.g. varicose veins, leg swelling, cold extremities, etc.Heart complaints: irregular beat, chest pain, etc.Breathing difficulties: breathlessness, cough, wheezing, pain on breathing, etc.Reduced bone density? e.g. Osteoporosis, osteopeniaDisturbance or changes in eyesight, Glaucoma, hearing; dizziness and balance problemsNumbness or tingling in the arms, legs or faceMuscular weakness; disturbance of balance or co-ordination; tremorAnxiety; depression; diagnosed psychiatric/psychologicalCancerDiabetesMultiple SclerosisEpilepsyM.E If you have ticked any of the above, please give further details below:
"Have you had a baby in the last six months?" YesNo If ‘yes’ please give further details: YesNo "Are you experiencing any disturbance or changes in your menstrual cycle?" YesNo If ‘yes’ please give further details: "Are you menopausal, postmenopausal?" YesNo If ‘yes’ please give further details: "If you've answered "yes" to any of the above please give appropriate details, including approximate dates where relevant."
Have you EVER had any serious illness or medical condition that you have not already told us about? YesNo Have you EVER had any surgery that you have not already told us about? YesNo Have you EVER had any significant accident or injury that you have not already told us about? YesNo Do you have any old injuries that still trouble you? YesNo If you've answered "yes" to any of the above please give appropriate details, including approximate dates where relevant
Is there any other information that you feel you should tell us in order to be able to safely take part in your Day Retreat, Workshop, Yoga Classes, Trapeze and Aerial Classes? I understand that private sessions, workshops and classes must be cancelled 48 hours in advance or student will be charged for the full rate of the session. Yes Disclaimer I, the undersigned, being aware of my own health and physical condition and having knowledge that my participation in any Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes may be injurious to my health, am voluntarily participating in the Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes with Zensace Yoga. Having such knowledge, I hereby release Zensace Yoga from any liability for accidental injury or illness, which I may incur because of participating in the said Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes. I hereby assume all risks connected therewith and consent to participate in the said Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes. I agree to disclose any physical limitations, disabilities, ailments or impairments, which may affect my ability to participate in the said Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes. With regards to all forms of exercise if you have any doubt about your level of health and fitness it is advisable to consult your GP prior to the commencement of any new fitness plan. The instructor must be informed of any injuries, handicaps or medical problems prior to joining the Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes. Zensace Yoga cannot accept responsibility for personal injury whilst participating in the Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes if: a) you have been advised against exercise based on a pre-existing health condition by your GP. b) you fail to observe the techniques &instructions given regarding safety. Yes I agree, and I acknowledge that I exercise at my own risk COVID-19 Waiver Form Addendum: Coronavirus/COVID-19 The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. Zenspace Yoga has put in place preventive measures to reduce the spread of COVID-19. However, Zenspace Yoga cannot guarantee that you will not become infected with COVID-19. Following government guidelines, we ask students not to attend classes if they are/or think they might be in breach of these (re: return travel, flu like systems, been in contact with someone that has COVID-19). ASSUMPTION OF RISK: By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury, illness, damage, loss, claim, liability, or expense, of any kind, that I may incur. WAIVER OF LIABILITY: I hereby release, covenant not to sue, discharge, and hold harmless Zenspace Yoga, its employees, agents, and representatives, from all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating to COVID-19. Please read carefully; I hereby agree to the following: I agree and acknowledge that I am fully aware that participation in this activity may involve risks and I accept all the risks of participating. I will progress at my own pace and I understand my physical limitations, so I am sufficiently self-aware to stop physical activity before I become ill or injured. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Day Retreat, Yoga Holiday, Workshop, Yoga classes,Trapeze/Aerial Yoga classes. In consideration of being permitted to participate in the Day Retreat, Yoga Holiday, Workshop, Yoga classes, Trapeze/Aerial Yoga classes, I knowingly, voluntarily, and expressly waive any claim I may have against Zenspace Yoga for injuries or damages that I may sustain as a result in participating in the Day Retreat, Workshop, Yoga classes, Trapeze/Aerial Yoga classes. My agreement acknowledges that I shall not now, or at any time in the future, bring any legal action against Zenspace Yoga, and/or any other person who may teach at Zenspace Yoga; and that this waiver is binding on me, my heirs, my spouse, my children, my legal representatives, my successors, and my assigns. My agreement verifies that I am participating in yoga at Zenspace Yoga with my doctor’s full approval. If you are under 18, you must have a parent’s agreement. My agreement is binding to this liability waiver from this day forth.
I, the undersigned, being aware of my own health and physical condition and having knowledge that my participation in any Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes may be injurious to my health, am voluntarily participating in the Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes with Zensace Yoga. Having such knowledge, I hereby release Zensace Yoga from any liability for accidental injury or illness, which I may incur because of participating in the said Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes. I hereby assume all risks connected therewith and consent to participate in the said Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes. I agree to disclose any physical limitations, disabilities, ailments or impairments, which may affect my ability to participate in the said Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes. With regards to all forms of exercise if you have any doubt about your level of health and fitness it is advisable to consult your GP prior to the commencement of any new fitness plan. The instructor must be informed of any injuries, handicaps or medical problems prior to joining the Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes. Zensace Yoga cannot accept responsibility for personal injury whilst participating in the Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes if: a) you have been advised against exercise based on a pre-existing health condition by your GP. b) you fail to observe the techniques &instructions given regarding safety. Yes I agree, and I acknowledge that I exercise at my own risk
Addendum: Coronavirus/COVID-19 The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. Zenspace Yoga has put in place preventive measures to reduce the spread of COVID-19. However, Zenspace Yoga cannot guarantee that you will not become infected with COVID-19. Following government guidelines, we ask students not to attend classes if they are/or think they might be in breach of these (re: return travel, flu like systems, been in contact with someone that has COVID-19). ASSUMPTION OF RISK: By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury, illness, damage, loss, claim, liability, or expense, of any kind, that I may incur. WAIVER OF LIABILITY: I hereby release, covenant not to sue, discharge, and hold harmless Zenspace Yoga, its employees, agents, and representatives, from all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating to COVID-19. Please read carefully; I hereby agree to the following: I agree and acknowledge that I am fully aware that participation in this activity may involve risks and I accept all the risks of participating. I will progress at my own pace and I understand my physical limitations, so I am sufficiently self-aware to stop physical activity before I become ill or injured. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Day Retreat, Yoga Holiday, Workshop, Yoga classes,Trapeze/Aerial Yoga classes. In consideration of being permitted to participate in the Day Retreat, Yoga Holiday, Workshop, Yoga classes, Trapeze/Aerial Yoga classes, I knowingly, voluntarily, and expressly waive any claim I may have against Zenspace Yoga for injuries or damages that I may sustain as a result in participating in the Day Retreat, Workshop, Yoga classes, Trapeze/Aerial Yoga classes. My agreement acknowledges that I shall not now, or at any time in the future, bring any legal action against Zenspace Yoga, and/or any other person who may teach at Zenspace Yoga; and that this waiver is binding on me, my heirs, my spouse, my children, my legal representatives, my successors, and my assigns. My agreement verifies that I am participating in yoga at Zenspace Yoga with my doctor’s full approval. If you are under 18, you must have a parent’s agreement. My agreement is binding to this liability waiver from this day forth.
