Yoga Intake & Consent Yoga for Survivors Intake & Consent Please complete the intake form below to register for SARA Roanoke's Yoga for Survivors program. If you prefer to submit your intake via email, please contact Laura Guilliams by emailing: lguilliams@sararoanoke.org. Name* First Last Pronouns Date of Birth* MM slash DD slash YYYY 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 Please select any service areas you would like to receive more information about: Counseling (free & confidential) Support Groups (free & confidential) Court/Systems Advocacy (free & confidential) Volunteer Crisis Advocacy Program Education/Outreach Programming 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?* SARA E-Newsletter Facebook Instagram SARA staff/volunteer SARA website Word of Mouth Other If other, please describe: What made you decide to participate in Yoga for Survivors and how do you think it could support you?*May we add you to our e-newsletter mailing list for SARA Roanoke supporters?* Yes, please! No, thank 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.CAPTCHA
Recent Comments