Registration

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If you are making a booking with Mel for the first time, please fill in the Registration form below before attending your session.

Registration Form

* Indicates required field

Name *

First

Last

Email *

Phone *

Gender *

Male Female

Emergency Contact *

First

Last

Emergency Phone Number *

How Did You Find Us ? *

Internet Flyer in Mail Referred By Friend Other

Would you like to receive information regarding Otway Yoga and any specials that may be on offer through our mailing list *

Yes No

Have You Had Any Of The Following (All information is private and will remain confidential) *

Diabetes Heart Disease / Condition High / Low Blood Pressure Stroke Asthma Chest Pain Arthritis Epilepsy Osteoporosis High Cholesterol Migraines / Head Aches Infectious Disease / Illness Cancer None

If Yes to the above, please provide details *

Are You Pregnant ? *

Yes No

If YES how many weeks pregnant ? *

Have you had any complications with this pregnancy? *

Have you had any complications with previous pregnancies? *

Do You Take Any Medications ? *

Yes No

If Yes describe the condition for which it is prescribed e.g. depression, thyroid function, anxiety etc. *

Do you have any injuries? *

Yes No

If Yes please provide details. *

I agree that i take full responsibility for any risks, injuries or damages known or unknown, which i might incur as a result of participation in any class with Otway Yoga *

I agree I disagree

Submit

Ph. 0409 850 047 www.otwayyoga.com.au [email protected]

HOME
ABOUT
TRAINING
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