Purusha Yoga School

part I - advanced training application

(300-Hour YTT / Yoga Therapy)

Name *
Name
Birthdate *
Birthdate
Phone Number *
Phone Number
Address *
Address
(name, phone, relationship)
Program you are applying for: *
Select one or both
Prerequisites: *
Check all that have been satisfied
Studio Preference
HEALTH SCREENING AND WAIVER OF LIABILITY
Do you have a heart condition? *
Do you feel pain in your chest when you do physical activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Do you have a bone or joint problem (back, knee, hip, etc.) that could be made worse by a change in your physical activity? *
Are you taking any medications of recreational drugs? *
Are you pregnant? *
Do you have a history of Diabetes? *
Do you have asthma or other pulmonary considerations? *
In consideration of participating in the activities provided by Purusha Yoga and the Purusha Studio, I do hereby waive, release, and forever discharge Purusha Yoga, the Purusha Studio, Joy Ravelli, and it’s officers, agents, employees, and representatives, any and all responsibilities or liability from injuries or damages resulting from my participation in any activities or the use of equipment. I understand that all forms of exercise are potentially hazardous. I understand there is a risk of injury or even death, and that I am voluntarily participating in these activities. I hereby agree to expressly assume and accept any and all risks of injury or death. I do hereby declare to be physically sound and suffering from no condition or illness that would prevent my participation in fitness activities. I understand that it is suggested that I consult with my physician as to proper physical activity for my specific needs.
Today's Date: *
Today's Date:
Name 1 *
Name 1
Signature:
If you are filling out this form online, you will be able to provide your signature on the first day of your training.