Health Indemnity Form

We require you to complete this form due to the physical nature of yoga and related activities.

We will use the following information to enable us to offer you the safest and most appropriate yoga postures for your current level of health and in the event of any incident that may require first aid treatment during the retreat.
The information provided will be treated with the strictest of confidence and will only be available to Just Relax management and the teacher(s) who will be delivering activities to you.
We will not share the information contained within this form with any other person except with your express consent.
For legal and insurance purposes we will retain this information for a period of 3 years from the end of the retreat. We will store this information securely.

Health

Any new exercise program should be undertaken with care – I strongly suggest you check with your Doctor/Health Provider if you suffer from any of the following. This list is by no means comprehensive and you should consult with your physician if you suffer any other condition not listed. Please let us know in the box below if you have any of the following:

Multiple sclerosis
Parkinson’s disease (or similar)
Meniere’s disease
Diabetes
Epilepsy or Seizure disorder
Dizziness
Surgery within the last 6 months
Mental illness
Fibro myositis
Disc disease
Carpal tunnel syndrome
Enlarged heart, heart valve problem or have suffered a heart attack in the past 2 years
Osteoporosis
Asthma
Chronic fatigue syndrome
Recurring headaches
Vertigo
Pregnancy
Hernia or ulcers
High or Low blood pressure
Severe arthritis of the spine
Hyperthyroid condition

Please let us know in the box below if you have or have ever had any of the following:

Cramps
Back pain/injury
Shoulder pain/injury
Wrist pain/injury
Neck pain/injury
Muscular pain
Knee pain/injury
Ankle pain/injury
Other

Do you smoke: Yes / No Are you taking any form of medication that may have some bearing on your yoga practice? Yes / No Please list medication and explain what you are being treated for.

What would you identify as the major cause of stress in your life at the moment?
What do you usually do to relieve this stress?
What is your current level of fitness?
Is there anything else we should know about your health that we have not covered above?

Your yoga

Have you practiced yoga before? What type of yoga? How long did you practice?
Are you currently attending any yoga or Pilates classes? Which one?
How often do you practice?
Is there anything you would like us to be aware of?
What would you like to get out of the yoga retreat? Please list everything you can think of.

Please read the following carefully and initial below. I understand that the instructions given throughout the sessions are intended as guidance only. I understand that while all due care will be taken by the teacher, they cannot be held responsible for my improper practice at any time. To ensure that no personal injury occurs, I agree to adjust my practice according to my limitations and the decision to perform any yoga postures remains mine. I declare that I will take full responsibility for myself during the retreat. I will notify the teacher before each session begins of any recent injury, illness, surgery or pregnancy. Many thanks for your time, Just Relax

I agree that my submitted data is being collected and stored.