Please complete this form each time you register for a class or purchase a drop-in / flex pass.

Please note – completing our Registration and Health Form DOES NOT register you for class! Receipt of payment confirms registration. See here for payment options.

First Name:

Last Name:

Phone:

Email:

Class Name:

Day / Time:

REMEMBER: Students and 65+ receive 10% off on full session classes only. Receive 10% off when taking 2 or more full session classes.

For most people physical activities should not pose any problem or health risks. However if you have any physical or medical conditions that may be aggravated by physical participation, you should consult your doctor or health care advisor as to whether you should participate in this program. You must also inform your instructor.

1) Do you have any health concerns or preexisting medical conditions?

YesNo

If yes, please specify:

2) List any prescription or non prescription medication you are taking and for what.

Please list any history of surgeries, major illnesses, chronic conditions, accidents, injuries or mental health concerns. Please list any dates that apply.

3) Are you pregnant?


If yes, Due date (yyyy-mm-dd ie. 2018-01-27) Please provide a doctors note.

4) What is your primary reason for taking this class?

that I am solely responsible for my health, safety, and well being. I release Every Day Sacred from any and all responsibility for damages incurred by injuries received while participating in this program.

Please submit the following text

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