Shakti Wellness Yoga Heath Awareness Form please complete and mail with a check to
Laura Marie 15 Charlemont Court Chelmsford, MA 01863 

NAME:                                                                                                EMAIL:

STREET:                                                                                  TOWN & ZIP:

HOME PHONE:                              WORK:                                       CELL:

DO YOU HAVE ANY EXPERIENCE WITH YOGA?  Please explain:

                        LIST ANY HEALTH ISSUES YOU ARE DEALING WITH AND DESCRIBE WHAT BODY PARTS ARE AFFECTED AND
                      HOW:

HOW LONG HAVE YOU BEEN DEALING WITH THESE SYMPTOMS?

HOW ARE YOU FEELING EMOTIONALLY?

PLEASE NOTE HOW THE FOLLOWING EFFECT YOUR SYMPTOMS (weather, time of day, emotional state, interpersonal
                      relationship, stress):

WHAT HAVE YOU DONE UP TO THIS POINT TO COPE WITH YOUR SYMPTOMS?

WHAT DO YOU HOPE TO GET OUT OF THIS CLASS?

Professional Disclosure Form and General Release

                            I am delighted to have you as a student. The following information will help you to get the most out of our         
                             classes.  Please read carefully and sign below.

                             1.   I have completed a thorough professional training in yoga and therapeutic yoga.  I do not diagnose or
                             prescribe conditions or treatments.  Our classes are much more than just physical exercise.  They are
                              transformative practices that integrate body, mind & spirit.  They are a way of encountering and releasing
                              physical, mental and emotional tensions to arrive at a deeper level of relaxation and awareness. 

                             2.  All programs involving physical movement involve a risk of injury.  By choosing to participate, you
                               voluntary assume a certain risk of injury.  The following guidelines will help you to reduce this risk.

Listen to and follow instructions carefully

Breath smoothly and continuously as you move and stretch

Do not hold your breath or strain to attain any position

Work gently; respect your body’s abilities and limitations

Don’t perform any movements that are painful

Ask if you are unsure how to perform a certain movement

Never hold a position longer than is comfortable for your body

Menstruating women may not want to practice inverted poses

Pregnant women must consult their health care professional

Consult your health care professional about your specific physical challenges

3.   It is always advisable to consult your health care professional before embarking on this program.  It is your responsibility to keep your teacher informed of conditions affecting you.

       4.  Awareness is fundamental to the practice of our program.  It is solely your responsibility to monitor each

         activity offered and determine whether it is appropriate to participate, and at what level it is appropriate to  

        participate.  Though    your teacher will be guiding you, you remain primarily responsible for your safety and well       

         being.

The teacher is not responsible for insuring the safety of the student beyond the duty to provide competent instruction.  The undersigned assumes all risk of damage or injury that may occur as a student in class and while following instructions at home.  In consideration of being accepted as a student, the undersigned releases and discharges Shakti Wellness and Laura Marie, her heirs and estate,  from any and all claims, demands, and causes of action of any nature, whether present or future, anticipated or unanticipated, known or unknown, that result from t h undersigned’s participation class practices.

Please remember that it is your responsibility to update your instructor on any changes in
              your health.  Not all yoga movements are appropriate for every body/condition.  It is strongly advised that you consult with your health care professional before beginning any program. 

I have read and agree to the above outlines conditions:

Student                                                                        date:

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Copyright © 2007 Shakti Wellness Yoga
Last modified: 01/05/08