Facilitated Healing Center YOGA REGISTRATION AND HEALTH FORM
Please PRINT this form and mail it with your 
check made payable to "Facilitated Healing Center"
TO: Facilitated Healing Center, 199 Shunpike Rd., Cromwell, CT 06416
Phone: 860-635-0509      E-Mail info@cromwellyogastudio.com  URL: www.cromwellyogastudio.com

NAME________________________________________

ADDRESS________________________________ TOWN__________  STATE____ ZIP CODE

PHONE_____________________ EMAIL_____________________________

CLASS_____________________ TIME & DAY________________________

MEDICAL INFORMATION:

What is your age ____? Please describe your present state of health:

Are you taking any long-term medication? If so, please name the drug and the reason you are taking it.

Please check any of the following that apply to you:
q  Chronic sinus condition q  High or low blood pressure q  Heart trouble q  Diabetes q  Recent surgery (name type)                 _____________________ q  Hypoglycemia q  Hernia	q Asthma q  Intestinal complications q  Ulcers q  Genito-urinary difficulties q  Arthritis q  Psychological therapy q  Epilepsy q  Past or present allergies (to what?)

Please mention in detail any other health or medical condition that you believe may be helpful for your
instructor to be aware of:

Please use this space to inform your instructor of any questions you may have relative to your
 full participation in this class:

DISCLOSURE AND RELEASE:
It is advisable to consult with a physician before participating in any exercise program. You are primarily responsible for your safety and well being.

I do hereby certify that the above information is true and complete to the best of my knowledge. I will assume all risk of damage or injury that may occur as a yoga student. I release and discharge Facilitated Healing Center, LLC or any of it’s instructors from any claims, demands, and actions of any nature that result from my participation in this class.

 SIGNATURE: _________________________           DATE: ____________