HYM Discovery Session Registration Form

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
E-mail* This field is required.
example@example.com
4
Phone Number
5
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
What are your primary goals:* This field is required.
Strength training
Flexibility
Balance
Stress relief
Improve fitness
Enhance well-being
Positive reinforcement
Weight management
Injury rehabilitation
7
What type of session are you interested in? (Please check all that applied)* This field is required.
Yoga Trapeze
Hatha Yoga
Yin Yoga
Family / Kids Yoga
8
On a scale of 1-10, how would you rate your level of stress?* This field is required.
9
Please check any existing or past conditions:
High/Low blood pressure
Back/neck pain
Knee pain
Tendinitis
Carpal Tunnel
Asthma/Short breath
Hip pain
Anxiety / depression
Pregnancy (current)
Insomnia
Broken / dislocated bones
Others
10
Any injuries or concerns I should be aware of?
11
Emergency Contact* This field is required.
Name
Phone Number
Relationship
Name
Phone Number
Relationship
12
Acknowledgement of Risk* This field is required.In any physical activity, the risk of serious physical injury is possible. Yoga and other activity is no substitute for medical diagnosis and/or treatment. The student assumes the risk of yoga or other activity and releases Flora Sze and Happy Yoga Minis from liability claims. I am participating in classes or workshops with Happy Yoga Minis (Flora Sze). I am aware of the physical risks involved with exercise and understand it is my personal responsibility to consult with my doctor regarding my participation, I have no medical condition which I am aware of, that would prevent me from taking part in classes or workshops, and I assume responsibility for any risk or injury I may sustain as a result of my participation I have read the above release and waiver of liability and understand its contents. I( understand that it is my responsibility to find a pace that suits me. I agree to the terms and conditions stated above.
Clear
13
Photo Release FormI grant to Happy Yoga Minis & Flora Sze, its representatives and employees the right to take photographs of me and my property in connection with the above-identified subject. I authorize Happy Yoga Minis & Flora Sze, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Happy Yoga Minis & Flora Sze may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web consent.
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