Name *

Name

First Name

Last Name

Gender *

Male

Female

Phone *

Phone

(###)

###

####

Email Address *

Date of birth *

Date of birth

YYYY

Emergency Contact *

Emergency Contact

(###)

###

####

Have you ever been diagnosed with a heart condition?

Yes

Do you feel chest pains at rest or during physical activity? *

Yes

Have you ever been recommended to take only medically supervised exercise? *

Yes

Have you ever been diagnosed with High blood pressure? *

Yes

Do you ever lose consciousness or control of your balance due to dizziness? *

Yes

Do you suffer from epilepsy? *

Yes

Are you pregnant or have given birth recently? *

Yes

Is there any other reason that exercise or activity may not be suitable for you? *

Yes

Do you have any injuries? *

Yes

Please provide further details if you answered "Yes" to any of the above questions. *

How did you hear about Bikram Yoga Nairobi *

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.

Yes I Agree

No I Disagree

Signature

Date

YYYY

Thank you for your Registration. We will contact you shortly.