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


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)