Has your child had or have any of the following:

Heart conditions

Blackouts

Migraines

Epilepsy

Allergies

Other medical conditions

Past or present injuries that might cause difficulties or pain

Are there any specific activities that your child cannot physically do?

Yes

No

Confirm your understanding and agreement of the following: *

• I have answered all questions to the best of my ability.
• If requested, I will obtain medical clearance for my child before he or she participates in the yoga classes.
  I understand that the teacher cannot give me medical advice on the fitness of my child and the information given by me is used as a guideline to assess my child's ability to do the yoga activities.
• I fully understand the nature of the classes my child is attending and I will take full responsibility for my child during the class.
  I understand that instructions in class are intended as guidance and, that while all due care will be taken by the teacher, he or she cannot be responsible for my child's improper practice at any time.
• I will notify the teacher before each class begins of any recent injury, illness or surgery experienced by my child.

I have read and understood the above statements and agree to the actions requested.