OLD course intake form

DEE WHY SCHOOL OF YOGA - EST 1993

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Course Intake Form

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Occupation *

What is your age? *

Less than 13 13-18 19-25 26-35 36-50 Over 50 Prefer not to say

Which best describes your experience with yoga? *

I’ve never practised yoga before I’ve been to a few classes I’ve been to a bunch of classes

Which best describes your current level of fitness? *

Challenged Average Good Excellent

Which best describes your current level of flexibility? *

Challenged Average Good Excellent

Please describe any regular exercise you undertake (e.g. walking, running, gym, Pilates) *

What are your main reasons for coming to yoga? *

Physical fitness Stretching and flexibility Increase vitality and energy Support for a specific injury or physical ailment Stress management Mental / emotional health Specific health condition

Please tell us a little bit about why you’re attending the beginner course and what you hope to get out of it? *

Please indicate if any of the following apply to you: *

Asthma or breathlessness Low blood pressure Spine or neck ailments Muscle / joint / tendon problems Recent surgery Illness or chronic conditions Anxiety / depression / stress / mental health Pregnant / post natal Other

Comments *

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* indicates required

Email Address *

First Name

Last Name

Address

Address Line 2

City

State/Province/Region

Postal / Zip Code

Country

Birthday

/ ( mm / dd )

Course Intake Form

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