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Next cohort starts January 15th, 2021!
Intake form YOCP-200
Delanie Dyck
2020-03-06T17:00:42-08:00
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)?
*
Stress reduction
Therapy
Flexibility
Spiritual growth
Overall well-being
Disease management
Any other reasons you'd like to share?
Are you currently experiencing any of the following conditions (check all that apply)?
*
Asthma
Low blood pressure
High blood pressure
heart/circulatory problems
dizzy/fainting spells
epilepsy/seizures
none
Are you currently experiencing any of the following conditions (check all that apply)?
*
Depression
Anxiety
PTSD
Muscular injury
Joint injury
Neck/back injury
Diabetes
none
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?
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