Spirit Moves
Health Form 2018
HEALTH AND INFORMATION FORM
Spirit Moves: Yoga, Pilates & Movement DATE:
Name: Class Location:
Address: Date of Birth: (optional)
Circle preference for phone.
Phone: (home) Work: Cell:
E-mail:
Occupation:
Yoga/Pilates Experience:
Other Activities:
Physical Challenges:
Physician: Medications:
Allergies: Medical Conditions:
Your reason for taking this class and what you hope to experience during the course of this class?
Additional information you would like me to know about you:
Emergency Contact: (name and phone number)
During the class there may be the opportunity for hands-on assistance. This is completely voluntary.
Do I have your permission to offer this type of assistance to you? Yes / No
I am pleased to have you as a student! The following information will help you get the most out of class and clarify my role as your instructor. Please read and sign.
All exercise programs involve a risk of injury. By choosing to participate in this class, you voluntarily assume a certain risk of injury. The following guidelines will help you reduce your risk of injury:
* Listen to and follow 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
* Do not perform any postures or movements that are painful
*If you are unsure of how to perform a certain posture/movement, ask me
* Never hold a posture or movement longer than is comfortable for your body
* Menstruating women may not want to practice inverted postures
*Pregnant women must consult their health care provider
It is always advisable to consult with your physician before embarking on any exercise program. Please inform me of any health conditions that could be affected by your practice of Yoga and Pilates. If in doubt, please ask me.
Awareness is fundamental to the practice of Yoga and Pilates. As a student, it is solely your responsibility to monitor each activity offered and determine whether it is appropriate to participate and what level it is appropriate to participate. Though I am your teacher, you remain primarily responsible for your safety and well-being.
As a professional, I am responsible to provide you with competent instruction. I am not responsible for insuring the safety of my students beyond the duty to provide competent instruction. By signing this release form, you hereby release Anne M Nelson as your yoga/pilates teacher from any and all liability for injuries that are not directly and proximately caused by my professional negligence and you assume all risk of damage or injury that may occur as a student in my yoga/pilates classes, both while attending classes and following instructions at home, this includes Yoga Teacher Pamala Lewis.
I have read, understood, and agree to the content of this Professional Disclosure and General Release form.
Print Name of Student Signature Date
This form will be kept on file. Please be sure to update me should the condition of your health change. It is recommended that you talk to your physician before beginning an exercise program.
If you have any additional questions, please call or email me at 860-535-0565 or spirit7moves@gmail.com.
Namaste.
Anne M Nelson, MA, RYT
Spirit Moves
8 Mill Village Pentway
North Stonington, CT 06359
Website: www.spirit7moves.com
About me: I have a Level 1 and 2 certification in Pilates Mindful Mat Technique from the Soma Yoga Center of Newport, RI. A certified Kripalu Yoga teacher (200 hours, completing 500 hours) and have been practicing Yoga for over 30 years. Yoga and Pilates are more than just a physical exercise. It is a practice that engages the mind, body and spirit. It is a way of releasing tension and allows a deeper level of relaxation and awareness. Pilates and Yoga will increase your flexibility, tone, strengthen and stretch your body. Both practices are empowering!
Spirit Moves: Yoga, Pilates & Movement DATE:
Name: Class Location:
Address: Date of Birth: (optional)
Circle preference for phone.
Phone: (home) Work: Cell:
E-mail:
Occupation:
Yoga/Pilates Experience:
Other Activities:
Physical Challenges:
Physician: Medications:
Allergies: Medical Conditions:
Your reason for taking this class and what you hope to experience during the course of this class?
Additional information you would like me to know about you:
Emergency Contact: (name and phone number)
During the class there may be the opportunity for hands-on assistance. This is completely voluntary.
Do I have your permission to offer this type of assistance to you? Yes / No
I am pleased to have you as a student! The following information will help you get the most out of class and clarify my role as your instructor. Please read and sign.
All exercise programs involve a risk of injury. By choosing to participate in this class, you voluntarily assume a certain risk of injury. The following guidelines will help you reduce your risk of injury:
* Listen to and follow 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
* Do not perform any postures or movements that are painful
*If you are unsure of how to perform a certain posture/movement, ask me
* Never hold a posture or movement longer than is comfortable for your body
* Menstruating women may not want to practice inverted postures
*Pregnant women must consult their health care provider
It is always advisable to consult with your physician before embarking on any exercise program. Please inform me of any health conditions that could be affected by your practice of Yoga and Pilates. If in doubt, please ask me.
Awareness is fundamental to the practice of Yoga and Pilates. As a student, it is solely your responsibility to monitor each activity offered and determine whether it is appropriate to participate and what level it is appropriate to participate. Though I am your teacher, you remain primarily responsible for your safety and well-being.
As a professional, I am responsible to provide you with competent instruction. I am not responsible for insuring the safety of my students beyond the duty to provide competent instruction. By signing this release form, you hereby release Anne M Nelson as your yoga/pilates teacher from any and all liability for injuries that are not directly and proximately caused by my professional negligence and you assume all risk of damage or injury that may occur as a student in my yoga/pilates classes, both while attending classes and following instructions at home, this includes Yoga Teacher Pamala Lewis.
I have read, understood, and agree to the content of this Professional Disclosure and General Release form.
Print Name of Student Signature Date
This form will be kept on file. Please be sure to update me should the condition of your health change. It is recommended that you talk to your physician before beginning an exercise program.
If you have any additional questions, please call or email me at 860-535-0565 or spirit7moves@gmail.com.
Namaste.
Anne M Nelson, MA, RYT
Spirit Moves
8 Mill Village Pentway
North Stonington, CT 06359
Website: www.spirit7moves.com
About me: I have a Level 1 and 2 certification in Pilates Mindful Mat Technique from the Soma Yoga Center of Newport, RI. A certified Kripalu Yoga teacher (200 hours, completing 500 hours) and have been practicing Yoga for over 30 years. Yoga and Pilates are more than just a physical exercise. It is a practice that engages the mind, body and spirit. It is a way of releasing tension and allows a deeper level of relaxation and awareness. Pilates and Yoga will increase your flexibility, tone, strengthen and stretch your body. Both practices are empowering!
