Please Fill out the Form below. 

All fields marked with  * are required. 

Name *
Name
Gender *
Phone *
Phone
Date of birth *
Date of birth
Emergency Contact *
Emergency Contact
Have you ever been diagnosed with a heart condition?
Do you feel chest pains at rest or during physical activity? *
Have you ever been recommended to take only medically supervised exercise? *
Have you ever been diagnosed with High blood pressure? *
Do you ever lose consciousness or control of your balance due to dizziness? *
Do you suffer from epilepsy? *
Are you pregnant or have given birth recently? *
Is there any other reason that exercise or activity may not be suitable for you? *
Do you have any injuries? *
Declaration and application *
I have read and fully understand this form, including the Bikram Yoga Nairobi terms and Conditions overleaf. I confirm that to the best of my knowledge the answers given by me are correct. I know of no reason why I cannot participate in any form of physical exercise or any of the activities detailed in Bikram Yoga Nairobi website or suggested by an employee or representative of the business. I acknowledge that any such suggestions from any employee or representative regarding exercise, healthcare or nutrition are neither diagnostic or prescriptive. I agree to notify you of any changes to the above answers that may occur in the future before continuing to exercise. By signing this form I agree to the use of my information as stated in this form and i apply to be a member of Bikram Yoga Nairobi subject to Bikram Yoga Nairobi Terms and Conditions.
Date
Date