Name * First Name Last Name Email Address * Phone * (###) ### #### Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * (Name/Relationship/Phone Number) Please check any existing or past conditions: * High Blood Pressure Low Blood Pressure Insomnia Glaucoma Anemia Anxiety/depression Headaches Neck Pain/Injury Back Pain/Injury Knee Pain/Injury Hip Pain/Injury Heartburn Low Blood Sugar Pregnant Gestational Diabetes Hyperemesis Gravidarum (severe morning sickness) Preeclampsia Postpartum Other Please list any other health concerns, injuries, allergies, or medical conditions. Estimated Due Date / Baby's Birthday (if applicable) MM DD YYYY What are some of your goals for this session? (examples - build strength, relaxation, meditation, flexibility, increase focus, decrease pain, therapeutic, pranayama/breathing practices, learn more about yoga, yoga philosophy, build an at home practice, etc.) * Please share anything else you would like me to know about you or any topics you would like to discuss that will help me provide great support for you. Policy * In any physical activity, risk of serious physical injury is possible. Yoga and other activities are no substitute for medical diagnosis and/or treatment. The student assumes the risk of yoga or other activity and releases the teacher, Samantha Hoppes, from any liability claims. I am participating in classes, private sessions, or workshops with Samantha Hoppes. I am aware of the physical risks involved with exercise and understand it is my personal responsibility to consult with my doctor regarding my participation. I have no medical condition, which I am aware of, that would prevent me from taking part in classes, private sessions, and/or workshops and I assume responsibility for any risk or injury I may sustain as a result of my participation. Purchase Policy: All private class packages and single private sessions are nonrefundable. All sales are considered final. All private class packages expire 6 months from the date of purchase. Extension requests due to medical reasons may be requested by emailing me at samhoppesyoga@gmail.com. Cancellation Policy: I understand that if I confirm a private session and cancel with less than 2 hours’ notice (“Cancellation”), I will forfeit the session fee paid for said session in the event of a Cancellation. I agree to pay a cancellation fee of $30 (30% of total session fee) if notified the day of said session. Please try to provide 24 hours notice if you have to cancel or reschedule. No charge will occur if given 24 hour notice. Also, I understand life happens so please notify me as soon as possible and terms may be mutually amended due to unforeseen circumstances. I have read the above release and waiver of liability and understand its contents. I understand that it is my responsibility to find a pace that suits me. I agree to the terms and conditions stated above. I agree Thank you for providing your information!
