Yoga for Health & Relaxation

Home
About Me
Class Details
Enrolment Details
- Enrolment Form
- Pay Online
Yoga CDs
Contact Me

... with Audrey Burking ...

YOGA REGISTRATION FORM

Please fill in the following form to register for a Yoga class. If you would prefer to mail your form in, a paper copy can be downloaded by CLICKING HERE. The following information will assist me in class preparation, and will be kept strictly confidential.

All fields with an * must be completed

Name *
Address *
Postcode *
Contact Phone Number *
Email *
Which class would you like to enrol in? * Yoga for Health & Relaxation: Tuesday mornings 10.00 - 11.30am Yoga for Health & Relaxation: Thursday evenings: 7.15 - 8.45pm Yoga for Health & Relaxation: Friday mornings: 10.00 - 11.30am Yoga for Spinal Health: Thursday evenings: 6.00 - 7.00pm
(select one class only)
GP *
Medical History: do you have, or have you ever had, any of the following? * Asthma Depression Dizziness Epilepsy Cancer Diabetes Heart disease Angina Abdominal surgery High blood pressure Osteoporosis Hearing impairment Back pain and/or stiffness Neck pain and/or stiffness Hip replacement Knee surgery/replacement Shoulder surgery
(Please make sure you have ticked all those which apply, before moving on to the next item)
Do you have a pacemaker? * Yes No
Are you currently taking any medications? * Yes No
If you answered yes to the above question please list the medications below
Have you had any recent (last 12 months) surgery/injuries? * Yes No
If you answered yes to the above, please provide a brief description.
Do you require an itemised receipt for a health fund claim? * Yes No
(If you answer yes to the above an itemised receipt will be given to you at the end of the term).
Do you wish to be included on our email mailing list? * Yes No
The Human Test *
In order to make sure you are not a robot, please put the answer to this question in the field above. What is 6+4?
Please make sure you have responded to all the above items before submitting this form. Thank you.
Made a mistake or two? Would you like to start again? Then feel free to click this button instead.

Thank you for taking the time to provide me with this information. Please be assured that your privacy will be protected. You can view our privacy policy at: View Our Privacy Policy.

Once you have submitted your form please make sure you proceed to the Pay Online page and make your payment. Thank you.

© 2012 Audrey Burking & Greg Horgan Contact Me