Yoga Intake & Consent

Name*

First Last

Pronouns

Date of Birth*

Participants must be 18 years or older.

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number*

Email Address*

Have you ever received SARA Roanoke services?*

Yes
No

Do you currently participate in a regular yoga practice?*

Yes
No

Do you have a temporary or permanent disability requiring specific accommodations during class?*

Yes
No

If yes, please tell us about your disability and the accommodations needed to make this class accessible for you.

Please list all physical, medical, and/or mental health conditions for which you have been treated or are currently in treatment:

Please list all past and current physical injuries as well as surgeries you have experienced with approximate dates:

Please list any medications you are currently taking:

Please list any allergies you have:

Do you have high blood pressure or a heart condition?*

Yes
No

Are you currently pregnant?*

Yes
No

Have you given birth in the past 6 months?*

Yes
No

How did you learn about our Yoga for Survivors series?*

If other, please describe:

What made you decide to participate in Yoga for Survivors and how do you think it could support you?*

Emergency Contact*

First Last Relationship to You

Emergency Contact Phone Number*

Liability Disclaimer & Notices: Please Read Carefully!*

I acknowledge and fully understand that I will be engaging in physical activities that may involve some risk of injury. I acknowledge and have been advised that it is my responsibility to consult with my physician with respect to any past or present injury, illness, health problem, or any other condition or medication that may affect my participation. I assume the foregoing risks and accept full personal responsibility for any personal injuries sustained which might incur as a result of participating in this program and discharge and hold harmless Laura Guilliams and all teachers, employees, and affiliates of SARA Roanoke from any claim, cause of action, or liability for damages arising from any personal injury to myself or other persons or property caused by my participation in the Yoga for Survivors series.

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Yoga for Survivors Intake & Consent

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