Student Info Form Name * First Name Last Name Email * Phone Number * (###) ### #### Date of Birth * MM DD YYYY Emergency Contact Name * Emergency Contact Number * Have you practiced yoga before? * Yes No If yes, please provide brief details of your yoga experience Do you have any medical issues, physical limitations or injuries that may impact your yoga practice? * Yes No If yes, please provide details below. Are you pregnant? If yes, please contact me before booking one of my classes. * Yes No N/A Have you given birth in the last six month? * Yes No N/A If yes, please let me know how long ago you gave birth and whether or not the birth was by C-Section. How did you hear about me/Chloe Tully Yoga? * Search Engine Friend or Family Member Facebook Instagram Momence Shakti Den Website / Timetable Other If Other, please provide details here: Would you like me to add your email address to my mail list so that you can stay up to date with news about my classes and workshops? * Yes No I'm already signed up Thank you!