Please fill out the following form to request a private yoga . A yoga instructor will call or email you to set up an appointment within 3 business days from the time of recieving request. 

This form also includes medical history information.

If you have specific questions about the form, please contact Suzi Shankweiler, Fitness Supervisor, by phone at 303-833-3660 x 114 or email at sshankweiler@cvprd.com. 

Name of Participant (required)

Date (required)

Age (required)

Gender (required)

Male

Female

E-mail Address (required)

Phone Number (required)

Emergency Contact Name (required)

Emergency Contact Phone (required)

Relationship to Participant (required)

Preferred Session Day(s) (required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Preferred Session Time(s) (required)

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Participant's Health History

Does your Physician know you are taking part in this exercise program? (required)

Yes

No

Describe your current exercise program: (required)

What would you like your yoga instructor to know about your health and fitness goals? (required)

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Do you now have, or have you had in the past? (Please explain “yes” answers in comments)

Have you had any pain or discomfort with exercising in the past? (required)

Yes

No

Any chronic illness or condition? (required)

Yes

No

Difficulty with exercise? (required)

Yes

No

Any advice from physician not to exercise? (required)

Yes

No

Surgery within the last 12 months? (required)

Yes

No

Pregnancy? Now or within the last 3 months? (required)

Yes

No

History of breathing or lung problems? (required)

Yes

No

Muscle, joint, or back disorder, or any previous injury still affecting you? (required)

Yes

No

Hernia or any condition that may be aggravated by lifting weights? (required)

Yes

No

Have you had any pain or discomfort with exercising in the past?

Yes

No

Comments

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CANCELLATION POLICY: Trainers need a minimum of 24 hours notice if you are unable to make your appointment. If you fail to do so, you will be charged the full amount for the session.

I have read and understand the above cancellation policy. I have reviewed and understand the Personal Trainer and Client Expectation document (see document below). I certify that to the best of my knowledge, the enclosed statements are true and I understand that I am exercising at my own risk. (required)

Agree

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

Date (required)

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Please Note: Payment is due prior to training sessions and consultations are included in the first paid session.