Please bring on your first visit and arrive 15 minutes early if you can if you have not prepaid for your class, session or workshop.

Student Intake Form (click for printable form)

Grounded By Yoga , LLC

1st Visit will be in: Canandaigua  _________    East Bloomfield: ____________  Other: ____________


Today’s Date: _______________

I ________________________(print name) understand that yoga, Pilates, Tai-Chi and any movement class includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, adjust the posture and ask for support from the teacher. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. I affirm that I alone am responsible to decide whether to practice yoga. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against Sandy Hicks, Wendy Stoddard, Grounded By Yoga LLC or any other instructor at Grounded By Yoga, LLC..

Signature:__________________________________________________Print: __________________________________________________

1. _______________________________________________________ (Mailing Address)
_______________________________________________________ (Phone) _______________________(Date of Birth)

2. ____________________________________________________ Email Address: (We send one newsletter per month….advising of any schedule change or special workshops and events at GBY

3. ____________________________________________________ How did you first hear of Grounded By Yoga? (If it was an existing student…please give name so we can give them class credit!)

4. Any previous Experience? No / Yes (list below your experience…or other studios you attended)
________________________________________________________________________________________ ________________________________________________________________________________________

5. Are you pregnant or have any medical concerns (chronic pain, cant be on your knees, recent surgeries, restrictions, joint replacements, what trimester are u in, etc )?

6. Briefly state why you chose to incorporate Yoga into your life? (ex: Injury Rehab Stress, Focus, Weight Loss Healthier Habits, Internal Peace, Fitness, Curious, Time for myself, my Wife made me…)
a. ______________________________________________________
b. ______________________________________________________

REFER A FRIEND OR LOVED ONE and YOU QUALIFY FOR THE REWARDS PROGRAM! ASK FOR DETAILS! Also….December 2013 – New Online Rewards System!!! Stay Tuned!