Name_____________________________________________________________________________

Address___________________________________________________________________________

City, State, Zip_____________________________________________________________________

Daytime Phone_____________________________________________________________________

Evening Phone_____________________________________________________________________

E-mail ___________________________________________________________________________

General Health Condition (Please list any serious illness or recent injury.)

Have you previously taken yoga, and for how long?

Please read and sign the following:
PROFESSIONAL DISCLOSURE FORM AND RELEASE

I am delighted to have you as a yoga student. The following information will help you get the most out of your yoga classes and clarify my role as a yoga teacher. Please read and sign below.

1. I am a certified Kripalu Yoga teacher and have completed a thorough professional training in yoga instruction, Kripalu yoga is much more than physical exercise. It is a transformative practice that integrates body, mind and spirit. Kripalu Yoga is a way of encountering and releasing physical, mental and emotional tensions to arrive at deeper levels of relaxation and awareness.

2. All exercise programs involve a risk of injury. By choosing to participate in my yoga classes, you voluntarily assume a certain risk of injury. The following guidelines will help you reduce your risk of injury:

  • Listen to and follow my instructions carefully.
  • Breathe smoothly and continuously as you move and stretch.
  • Do not hold your breath or strain to attain any positions.
  • Work gently, respecting your body's abilities and limits.
  • Don't perform postures or movements that are painful.
  • Ask me if you are unsure how to perform a certain movement.
  • Menstruating women should not practice inverted postures.
  • Pregnant women must consult their health care provider.

3. It is always advisable to consult with your physician before embarking on any exercise programs. The health evaluation form above must be complete to inform me of any health conditions that could be affected by your practice of yoga. If in doubt, please ask me about your condition.

4. Awareness is fundamental to the practice of Kripalu Yoga. As a student, it is solely your responsibility to monitor each activity offered and determine whether it is appropriate, and at what level it is appropriate to participate. Though I am your teacher, you remain primarily responsible for your safety and well being.

5. As a professional, I am responsible to provide competent yoga instruction. I am not responsible for insuring the safety of my students beyond this duty to provide competent instruction.

6. By signing this form you hereby release Marcia Trachtenberg from any and all liability for injuries that are not directly and proximately caused by their professional negligence.

I have read, understood, and agree to the content of the Professional Disclosure Form and Release.

Signature _____________________________________ Date __________________