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MitchAnne Registration
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Disclaimer Statement    

 

I have read, understand and agree with the above Disclaimer Statement : Yes / No

 

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Your Name:   
First
Middle
Last
 Date of Birth:   
 Gender:    Male / Female
 Occupation:   
 Marital Status:    Single / Married / Divorced
 Contact Phone:   
Home
Work
Cell
 E-Mail Address:   
Mailing Address:   
Street :  
Apt. # :  
City :  
State :  
Zip Code :  
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    What classes are you interested in taking? 

   Yoga

 Meditation 

Fertility Therapy
   Tai-Chi
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    I would like to take: Private Classes    / Group Classes 

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    What are you goals in training?

   Physical fitness    Self-confidence and Positive attitude
   Weight control    Stress relief / Relaxation
   Enlightenment    Improve concentration
   Emotional stability and Peace of mind

 Fertility
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Do you have any previous or are you presently in training?
If so, please specify for how long:
Type How long?
Yoga
Tai-Chi
Meditation
Martial Arts
Ki-Gong
Other (Please Specify) :

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    Please select any of the following health conditions you may have: 

   Headaches    Diarrhea
   Insomnia    Constipation
   Back Pain    Stress
   Neck Pain    Depression
   Shoulder pain    Nervousness
   Allergies    Memory loss
   Chronic fatigue    High blood pressure
   Breathing problems    Low blood pressure
* Please list and/or explain any additional health information,
including current medications, and medical surgeries you have had:

What is your height? 

What is your weight? 

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How did you hear about MitchAnne Yoga & Tai-Chi?  
Personal Referral (Name ?) :  
Flier or Brochure (Where ?) :  
Website (Which ?) :  
Other (Please Specify ?) :  
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Please include any additional questions
or comments you may have here :

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