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Student Registration Form
  1. Student Information

  2. Full Name(*)
    Please use only letters in your name.
    Please enter your First and Last name
  3. Address 1(*)
    Please use only numbers and letters in your address.
    Please enter your address
  4. Address 2
    If necessary, please enter any additional details about your address.
  5. Town/City(*)
    Letters and numbers only please.
    Please enter the town/city you live in.
  6. Postal Code(*)
    Please use the format: a1b 2c3
    Please enter your postal code
  7. Daytime Phone Number(*)
    please use the format (123-456-7890).
    Please enter the best number to reach you at during the day.
  8. Evening Phone Number(*)
    Please use the format (123-456-7890)
    Please enter the best number to reach you during the evening.
  9. Email address
    Please enter a valid email address.
    Please enter a valid email address.
  10. Emergency Contact

  11. Emergency Contact(*)
    Please use only letters for the person's name.
    The name of a person we can contact in case of an emergency.
  12. Contact phone number(*)
    Please use the format: (123-456-7890)
    Please enter your Emergency Contact's phone number.
  13. Relationship(*)
    Please use letters only.
    How are you connected to your emergency contact?
  14.  
  1. Questionnaire

  2. Previous Experience(*)
    Please choose one or the other.
  3. Expected Benefits
    Invalid Input
  4. Class Requested








    At least one box must be checked.
    Please choose the night that works best for you. Placement can not be guaranteed.
  5. Prior/Current Conditions



















    Invalid Input
    Do you have any of the medical and or physical conditions shown?
  6. Other (please explain)
    Invalid Input
  7. Medication/Care
    Invalid Input
    Are you presently taking any medication, and or under the care of a physician?
  8.  
  1. Acknowledgement and Waiver

    Please be aware that the yoga instructor and Balanced Body Yoga does not assume any responsibility for determining your medical fitness to participate in a class, nor assumes any responsibility for any injuries to you or loss of property by you in or about the premises. It is the responsibility of the student to inform his or her instructor of any medical conditions (i.e. high blood pressure, joint problems, eye problems etc.) which should be taken into consideration while practicing yoga.

    It is my (the student’s) responsibility to ask for clarifications on anything that I do not understand. I will not put my body in any position that does not feel comfortable. If I feel any pain I will stop immediately. I understand this class is for me to develop an awareness of my body and will learn to heed the messages it sends me. I agree to waive claims against any persons connected with practice for any injuries I may sustain and assume full responsibility for all my actions related to practice.

    Submitting this registration form does not guarantee a placement in a particular yoga class. You will be contacted by the teacher by email, confirming the date and time of the next available class.

    Please make payment in the form of cash, cheque, or email money transfer. Payment details should be discussed with the teacher.

    Registration is complete upon receipt of payment.

    There are no refunds. Classes may be made up within the same session only - if space permits. 10 class punch card: All classes must be used within the same session and can not be carried over to a future session: no exceptions.

    Agree to Terms

    By clicking the SUBMIT button below, I understand and agree to the terms and conditions set out in this form.

News and Messages

Register for Fall 2015 Classes

Fall 2015 Classes ready for registration

Tuesdays: 7pm

Saturdays:  9am

 

More Details    Register Now

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