Please bring on your first visit & arrive 15 minutes early (if you can) for your 1st visit.
Student Intake Form (click for printable form)


Grounded By Yoga , LLC

STUDENT INTAKE FORM

Today’s Date: ________1st Visit will be in: Canandaigua___ East Bloomfield: ___ Retreat:___Other:___

I ________________________(print name) understand that Yoga 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 Studios & Yoga Teacher Training Center LLC (GBY) or any other instructor at GBY.

Signature:__________________________Print: ___________________________

1. ________________________________(Mailing Address)
_________________________________
_________________________________
_________________________________(Phone) ______________________(DOB)_____________
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. List any medical concerns, aches, pregnancy, recent surgeries, (chronic pain, cant be on your knees, recent surgeries, restrictions, joint replacements, what trimester are you 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. _________________________________
7. Your teacher has been professionally trained to assist (light touching). Would you mind receiving periodic assists? Yes or No

REFER A FRIEND OR LOVED ONE and YOU QUALIFY FOR THE REWARDS PROGRAM! Receive $20 on your account if you refer someone and they purchase a full package (excludes intros and specials)