Medical Information and Release for New Students

Name:____________________________________________________________________________
Address:__________________________________________________________________________
City, State, Zip:____________________________________________________________________
Email address:_____________________________________________________________________
Date of Birth:_____________________________ Phone Number:____________________________

Emergency Contact (Name and Phone): _________________________________________________

Please list any current or chronic medical conditions and medications (pregnancy, illness, pain, injury, etc):

Waiver: In consideration of my enrollment as a student at Bikram Yoga Portsmouth, in New Hampshire, I represent and agree as follows:
I have been examined by a physician in the past year and have been found by such physician to be in good physical health and am fully able to perform the yoga excercises that I am to learn and perform at Bikram Yoga Portsmouth.
I will faithfully FOLLOW ALL INSTRUCTIONS given to me as to when, where and how to perform the yoga excercises; it being understood by me that any deviation by me from such instructions will be at my own risk.
I will not hold you, your partners, instructors, or employees responsible for any injuries suffered by me caused in whole or in part by my failure to faithfully follow the instructions of you or your instructors, or by any physical impairment of mine not fully disclosed to you by me in writing.
I understand and acknowledge that I am to receive instruction in yoga theory and exercise only, and will not hold you, your partners, instructors, or employees to any higher standard of care than that applicable yoga theory and exercise.
The fee paid herewith in non-refundable.
Signature________________________________________________________ Date______________
(parent or guardian if under age 18)

Bikram Yoga Portsmouth : 800 Islington Street, Portsmouth, NH 03801