Application

ICY™ INITIATION PROGRAMME – APPLICATION

Name: *
Gender: *
Date of Birth: *
 /  / 
Address: *
Address Line 2: *
City / Town: *
Postal / Zip code: *
Country: *
Mobile no: *
Home no:
E-mail: *
Confirm E-mail *
I want to receive future updates about the website
Occupation: *
How did you hear about Health in Mind?
Do you have any previous Yoga Experience? *
If so, for how many years?
If so, what style/s are you practiced in?
Other yoga style/s:
Around how often do you practice?
1/2
Weight in kilograms: *
Height in metres: *
Do you have any health conditions? *
If so, please specify:
Other health condition/s:


Please make sure to inform us of any new conditions you may develop, as this may have adverse effects, possibly grave, if not handled properly during the sessions.

Do you smoke? *
Do you exercise regularly? *
If so, how often do you exercise?

Please list an emergency contact person or persons:

First Contact Name: *
First Contact Number: *
Relationship to First Contact: *
Second Contact Name:
Second Contact Number:
Relationship to Second Contact:
(Verification) What is 4 times 7?


By submitting this application, you acknowledge that you state and agree to the following:

I am in good health or any condition I have is medically managed, and feel confident in my ability to participate safely in Health in Mind's Yoga sessions.

2/2

Comments are closed.