______________________________________________
Last name		First name
______________________________________________
Address
______________________________________________
City	State	Zip code
______________________________________________
Telephone (home)		Telephone (work)
E-mail: ______________________________
Referred by: _____________________
How do you think a yoga class practice can serve you? ______________________________________________ ______________________________________________
In order for the yoga teacher to suggest yoga practices that are most suitable for my physical condition, I will inform them of: _uncontrolled high blood pressure,  _detached retina, _glaucoma,  _infection or inflammation of eyes or ears, recent or  _chronic injury or inflammation of: back, knees, shoulders, and hip, or any other condition that may affect my yoga practice. We currently do not offer classes for pregnant women.
I am attending this class because: ___________________ _____________________________________________
Please notify me if you offer classes during these days and times: ________________________________________ _____________________________________________
The Balance Group maintains a database and will attempt to contact students in the event of a class cancellation or schedule change. The Balance Group respects your privacy and will not sell or share your information with others. You may opt-out of updates, news, and events by checking below or by sending an email at a later date.
__ Please do not send updates of The Balance Group classes and events.
__ Please do not send updates of yoga, health news, and events.
Signature: _____________________			Date: ________