Intake form YOCP-200

YOCP-200 Student Intake

Please complete this form to the best of your ability. Your information will be kept confidential and is used to ensure both your safety and the safety of the instructors. It will not be disclosed to anyone outside of the teaching faculty with out your written consent, will be kept secure, and will be destroyed after 3 years.

Your name*
Preferred pronoun*
- She/her
- He/him
- They/them
Emergency Contact Name*
We will contact this person in the event of an emergency and/or if we have concerns about your well-being.
Emergency Contact Phone #*
Please provide the best number to reach them at in case of an emergency.
Emergency Contact relationship to you*
Please let us know who they are.
Have you practiced yoga before?*
- Yes
- No
If yes, what are your reasons for practicing yoga (check all that apply)?*
Any other reasons you'd like to share?
Are you currently experiencing any of the following conditions (check all that apply)?*
Are you currently experiencing any of the following conditions (check all that apply)?*
Are you pregnant? If yes, which trimester?*
Do you have any allergies we need to be aware of?*
If yes, what are they?
Are you currently taking any medications we need to be aware of?*
If yes, what are they?
Is there anything else you need/would like to share with us?