Registration Information&Release FormPlease fill out the following form for our records. Thank you! Name * First Name Last Name Birthdate * MM DD YYYY Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Please list your emergency contact and their phone number. * What is your Due Date? * MM DD YYYY What is your occupation? Who is your Care Provider and phone number? * Have you been advised not to exercise? * Yes No Are you exercising now? * Yes No If yes, please describe: Is this your first pregnancy? * Yes No Is this your first birth? * Yes No If not, please briefly describe your previous experiences. Please check any conditions that you experience or have experienced: Diastasis Recti Prolapse Pain Pressure Incontinence Other If you checked 'other', please explain: Have you had prior yoga experience? * Yes No How did you hear about our classes? Facebook Referral Website Flier Returning Client Other Please check any other services you may be interested in: Birth boot camp for couples Private Yoga Therapy Infant Massage Postpartum and core exercise Postpartum Support Group Postpartum Doula Release and Waiver * NOTE: Any program of physical activity will involve a certain amount of strenuous exercises, depending on participant’s current activity level. For this reason, it is recommended that participants in this class with any concerns check with their Care Provider before beginning any exercise program. The information provided in this class should not substitute or replace medical advice. RELEASE AND WAIVER I agree that the above information is correct AND agree to practice within my own comfort level and to inform my instructor of and discontinue any exercises that cause pain or discomfort. I have asked and received permission from my provider to participate in yoga classes taught by Stacy F. Sandel, LLC. I release Stacy F. Sandel, LLC and Adaptive Therapies from any responsibility of injury to myself or unborn child that could result from participation in this class. Agree Disagree Sign Here * By typing my name below, I agree to the release and waiver, and certify that all information provided is correct. First Name Last Name Today's Date: MM DD YYYY Thank you!
