class_registration

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MitchAnne Registration

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Disclaimer Statement

Please exercise according to your body’s personal limitations taking necessary precautions to not overdue any exercise. These series of exercises are only recommendations to improve your health. If you have or have had an illness or limiting condition, please consult your physician before participating in any exercise program. MitchAnne Yoga & Tai-Chi and its instructors are not liable for any injury that you may incur upon yourself.

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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