Please Fill out the Form below. All fields marked with * are required. Name * First Name Last Name Gender * Male Female Phone * (###) ### #### Email Address * Date of birth * MM DD YYYY Emergency Contact * (###) ### #### Have you ever been diagnosed with a heart condition? Yes No Do you feel chest pains at rest or during physical activity? * Yes No Have you ever been recommended to take only medically supervised exercise? * Yes No Have you ever been diagnosed with High blood pressure? * Yes No Do you ever lose consciousness or control of your balance due to dizziness? * Yes No Do you suffer from epilepsy? * Yes No Are you pregnant or have given birth recently? * Yes No Is there any other reason that exercise or activity may not be suitable for you? * Yes No Do you have any injuries? * Yes No 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 MM DD YYYY Thank you for your Registration. We will contact you shortly.