Yin Yoga for Fertility Enrollment Form 

Please note that it is a prerequisite to complete this form before participating in a class with Blueberry Yoga. This information is important and it helps us design the classes in a way that keeps you safe so please complete it as soon as you can.

It will take about 5 minutes.

 

Please complete the form below

Section A - Personal Information
Name *
Name
Address *
Address
Name of Emergency Contact *
Name of Emergency Contact
Which best describes your current situation *
Are you currently receiving IVF or other Fertility Treatment *
Section B - Health Information
High Blood Pressure Low Blood Pressure Recent Surgery Chronic Pain Heart Condition Cancer Stroke Diabetes Ulcer Headaches Hernia Epilepsy Arthritis Anxiety Insomnia Depression Spinal Injury Asthma Joint Replacement Back conditions Pelvic Instability Osteoporosis Thyroid Condition Other
Section C - Current Exercise
Section D - Agreement
It is important to be comfortable and pain-free throughout all activities in class and remain within your personal limitations. If you experience pain or discomfort in any of the practices – STOP – and seek advice *