Please complete this form before your first prenatal yoga class with me Name * First Name Last Name Email * Phone (###) ### #### Emergency contact (###) ### #### How is your pregnancy going? Is there anything I need to know? Are you pregnant with multiples? Yes No How many weeks pregnant are you? Please note you must be 12 weeks pregnant or more to attend prenatal yoga classes. During your pregnancy have you experienced any of the following? Morning sickness Headache Diabetes Heartburn Sciata Asthma Lower back pain High or low blood pressure Dizziness Pelvic pain/PGP Carpal tunnel syndrome A low lying placenta None of the above During your pregnancy have you experienced any of the following? (If so, you may not be able to take part) Vaginal bleeding Placenta previa (marginal or complete) Pre-eclampsia None of the above As far as I am aware, I have disclosed to my teacher all information regarding my pregnancy relevant to the practice of prenatal yoga. I take full responsibility for all applications of yoga I practice in class and outside the class during my pregnancy. I fully understand that these recommendations, ideas or techniques expressed and described in these classes cannot be regarded as a substitute for the advice of a qualified medical practitioner. Any uses to which the recommendations , ideas and techniques are put are at my sole discretion and risk. * I agree I consent to my data being held for 5 years, for insurance purposes. * Yes I have read and agreed to the Terms and Conditions Refunds will not be given for cancellations with less than one weeks notice before the block starts. You may roll one session per block over to the next session if you are unable to attend. Mother Your Way cannot be held responsible for any decisions that you make regarding your pregnancy and birth. Any questions or doubts you have about you the use of Hypnobirthing or yoga should be taken up with your health care professionals. Yes Thank you!