Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Physical Limitations, Injuries, etc.

Please list any limitations or injuries

Referred By

Please indicated if you were referred by a current Heart & Soul Yoga Member

Date

YYYY

Message Heart & Soul Yoga and Wellness

Please add any additional information

Agree and Understand

I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Yoga Classes and Workshops. I represent and warrant that I am physically fit and I have no medical condition which would prevent mu full participation in the Yoga Classes and Workshops.

I agree with the above Information is correct and complete

Please Check Box to Submit

Agree and Understand

Forms

New Client Intake Release Form