Cherubs Yoga - Yoga, Pregnancy Yoga and HypnoBirthing

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Pregnancy Yoga

This registration form is only for those who are joining a pre-natal or post-natal yoga class.

You do not need to complete the form if you are enrolling
for Regular Yoga classes or HypnoBirthing.

Once you have received confirmation that there is a place for you on one of our pre-natal or post-natal yoga classes please complete the form below. Thank-you.

The information you provide will be held in the strictest confidence.

If you have not yet applied for a place in a class please contact us first.

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Name*:

Address*:

Contact telephone no*:

Email address*:

Emergency contact nos:

Doctor's name:

Address of surgery:

Telephone no of surgery:

Please give your reasons for attending this class and what you would like to achieve by practising yoga:

Have you practised yoga before? If yes, what type and for how long?:

Please list any past operations, conditions or injuries plus any current medical problems such as asthma, diabetes, high/low blood pressure, back or neck pain. Please include details of any current medication or treatment:

Pre-natal - Is this your first pregnancy?*:
Yes
No

Pre-natal - How far into the pregnancy are you?:

Pre-natal - Do you have a history of difficult or complicated pregnancies?:

Post-natal - When did you give birth?:

Post-natal - Did you have a Caesarean section or a particularly difficult birth?:

Disclaimer: Please be advised that by participating in these classes students are assuming all risks of injury that may result. The teacher shall not be liable for any claims for injuries or damages whatsoever resulting from attending these classes. By ticking the box below I agree to the above disclaimer and confirm that I have obtained permission from my midwife or doctor to attend these classes.*:
I agree to this disclaimer
I do not agree to this disclaimer

Today's day*:

Current Month*:

Current Year*:

Type in the CAPITAL letters shown and click SEND*:

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Once you have submitted this form you will receive an email confirmation within 24 hours.
This email will include details of the time of your class and other general class information.

The cost of each class is £8.00. This is payable on the day at the start of class by cash or cheque.
Please make cheques payable to: Maggie Bantick

'Cherubs Yoga', The Centre for Natural Health, 14-16 The Broadway, Wickford, Essex, SS11 7AA.