Waiver Form

I consent to providing my personal and medical information and understand that this information is kept private and confidential between myself and Lynnette Gouws from Ananda Wellness. Please note that by completing this sign you will receive relevant email newsletters.

Yes

Emergency Name and Contact

Medical Practitioner Name and contact details

Do you have any of these conditions I should be aware of:

If select other above:

Please specify and explain any conditions marked above or any other conditions you may have and include if you are receiving treatment from your Medical Practitioner:

If Pregnant was selected above, Please give your Trimester details and anything specific I should be aware of

Do you have Neck / Back or Spine Injuries currently or from the past

Yes No

Do you have any joint injury (ankle, knee, hip, shoulder, elbow)

Yes No

Do you have any muscular injury

Yes No

Any other medical condition, injury or disability or recent surgery?

I confirm that all personal and medical information provided in this form is true and correct and should there be any changes it is my responsibility to inform Lynnette Gouws from Ananda Wellness via email immediately.

Yes

I consent to Lynnette Gouws from Ananda Wellness contacting my Medical Practitioner and Emergency Contact should any emergency occur during any Yoga class, workshop etc

Yes No

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