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Costello Yoga and Fitness

Be Fit – Be Healthy – Be Happy

 

The information you provide us below ensures the highest level of safety and care can be met.  If you do not inform us of any health, injuries or change in your health status we may not be able to ensure that you get the most out of the program.  All information provided by you will remain confidential.

CONSENT AND ACKNOWLEGDMENT

I declare that the answers I have given are true to the best of my knowledge.

I declare that I have not withheld any information that may impact on my ability to participate in the program.

I agree that I will not take any legal or illegal substances before or during the program that may affect my Judgment or physical responses.

I am aware that during my participation in the program certain risks or dangers may occur including physical exertion to which I may not be accustomed, including but not limited to vigorous stretching and postures.

I acknowledge that my participation in the program carries risks.  I accept the risks associated with the program and the possibility of personal injury, loss or damage resulting there from and agree to hold Costello Yoga and Fitness, its employees, contractors or agents free from any and all liability, actions, claims and demands of any nature whatsoever.

In entering the program I am not relying on any representations made by or on behalf of Costello Yoga and Fitness but do so of my own free will.

In the event that I suffer injury Costello Yoga and Fitness, have my consent to administer first aid or may arrange such medical treatment as it shall consider necessary for my safety.

I accept that the program is not a substitute for medical treatment.

I agree that it is my responsibility to notify Costello Yoga and Fitness of any material change to the information provided in this registration form including any material change in my medical status.

Date: November 24, 2020 

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
In accordance with our legal obligations with The EU General Data Protection Regulation we would like to inform you that by completing our registration forms, Costello Yoga and Fitness will process your personal information to enable us to provide our services to you. We now seek your explicit consent that we may collect and process your personal information. You may withdraw your explicit consent (in writing) at any in the future. For further information on how we process your personal information please refer to our privacy statement on www.costelloyogaandfitness.com*
Do you suffer from, or have you in the past suffered from any of the following medical conditions? (Please tick as many boxes as needed)
Asthma
Epilepsy
Osteoporsis/Osteopania
Diabetes
Neck Injury
High Blood Pressure
Back Pain
Muscle Injury
Headaches/Migraines
Other (please specify)

Other (please specify)

In the last 5 years have you been admitted to hospital or had any medical procedure or surgery. Please provide details:

Do you suffer from any other medical condition not already referred to above?
Women Only:
Hysterectomy
Menopausal Challenges
Caesarean Delivery
Early Termination of Menses
Are you Pregnant?

Have you practiced yoga before and if yes, for how long?
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
In accordance with our legal obligations with The EU General Data Protection Regulation we would like to inform you that by completing our registration forms, Costello Yoga and Fitness will process your personal information to enable us to provide our services to you. We now seek your explicit consent that we may collect and process your personal information. You may withdraw your explicit consent (in writing) at any in the future. For further information on how we process your personal information please refer to our privacy statement on www.costelloyogaandfitness.com*
Do you suffer from, or have you in the past suffered from any of the following medical conditions? (Please tick as many boxes as needed)
Asthma
Epilepsy
Osteoporsis/Osteopania
Diabetes
Neck Injury
High Blood Pressure
Back Pain
Muscle Injury
Headaches/Migraines
Other (please specify)

Other (please specify)

In the last 5 years have you been admitted to hospital or had any medical procedure or surgery. Please provide details:

Do you suffer from any other medical condition not already referred to above?
Women Only:
Hysterectomy
Menopausal Challenges
Caesarean Delivery
Early Termination of Menses
Are you Pregnant?

Have you practiced yoga before and if yes, for how long?
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
In accordance with our legal obligations with The EU General Data Protection Regulation we would like to inform you that by completing our registration forms, Costello Yoga and Fitness will process your personal information to enable us to provide our services to you. We now seek your explicit consent that we may collect and process your personal information. You may withdraw your explicit consent (in writing) at any in the future. For further information on how we process your personal information please refer to our privacy statement on www.costelloyogaandfitness.com*
Do you suffer from, or have you in the past suffered from any of the following medical conditions? (Please tick as many boxes as needed)
Asthma
Epilepsy
Osteoporsis/Osteopania
Diabetes
Neck Injury
High Blood Pressure
Back Pain
Muscle Injury
Headaches/Migraines
Other (please specify)

Other (please specify)

In the last 5 years have you been admitted to hospital or had any medical procedure or surgery. Please provide details:

Do you suffer from any other medical condition not already referred to above?
Women Only:
Hysterectomy
Menopausal Challenges
Caesarean Delivery
Early Termination of Menses
Are you Pregnant?

Have you practiced yoga before and if yes, for how long?
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
In accordance with our legal obligations with The EU General Data Protection Regulation we would like to inform you that by completing our registration forms, Costello Yoga and Fitness will process your personal information to enable us to provide our services to you. We now seek your explicit consent that we may collect and process your personal information. You may withdraw your explicit consent (in writing) at any in the future. For further information on how we process your personal information please refer to our privacy statement on www.costelloyogaandfitness.com*
Do you suffer from, or have you in the past suffered from any of the following medical conditions? (Please tick as many boxes as needed)
Asthma
Epilepsy
Osteoporsis/Osteopania
Diabetes
Neck Injury
High Blood Pressure
Back Pain
Muscle Injury
Headaches/Migraines
Other (please specify)

Other (please specify)

In the last 5 years have you been admitted to hospital or had any medical procedure or surgery. Please provide details:

Do you suffer from any other medical condition not already referred to above?
Women Only:
Hysterectomy
Menopausal Challenges
Caesarean Delivery
Early Termination of Menses
Are you Pregnant?

Have you practiced yoga before and if yes, for how long?
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
In accordance with our legal obligations with The EU General Data Protection Regulation we would like to inform you that by completing our registration forms, Costello Yoga and Fitness will process your personal information to enable us to provide our services to you. We now seek your explicit consent that we may collect and process your personal information. You may withdraw your explicit consent (in writing) at any in the future. For further information on how we process your personal information please refer to our privacy statement on www.costelloyogaandfitness.com*
Do you suffer from, or have you in the past suffered from any of the following medical conditions? (Please tick as many boxes as needed)
Asthma
Epilepsy
Osteoporsis/Osteopania
Diabetes
Neck Injury
High Blood Pressure
Back Pain
Muscle Injury
Headaches/Migraines
Other (please specify)

Other (please specify)

In the last 5 years have you been admitted to hospital or had any medical procedure or surgery. Please provide details:

Do you suffer from any other medical condition not already referred to above?
Women Only:
Hysterectomy
Menopausal Challenges
Caesarean Delivery
Early Termination of Menses
Are you Pregnant?

Have you practiced yoga before and if yes, for how long?
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
In accordance with our legal obligations with The EU General Data Protection Regulation we would like to inform you that by completing our registration forms, Costello Yoga and Fitness will process your personal information to enable us to provide our services to you. We now seek your explicit consent that we may collect and process your personal information. You may withdraw your explicit consent (in writing) at any in the future. For further information on how we process your personal information please refer to our privacy statement on www.costelloyogaandfitness.com*
Do you suffer from, or have you in the past suffered from any of the following medical conditions? (Please tick as many boxes as needed)
Asthma
Epilepsy
Osteoporsis/Osteopania
Diabetes
Neck Injury
High Blood Pressure
Back Pain
Muscle Injury
Headaches/Migraines
Other (please specify)

Other (please specify)

In the last 5 years have you been admitted to hospital or had any medical procedure or surgery. Please provide details:

Do you suffer from any other medical condition not already referred to above?
Women Only:
Hysterectomy
Menopausal Challenges
Caesarean Delivery
Early Termination of Menses
Are you Pregnant?

Have you practiced yoga before and if yes, for how long?
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
In accordance with our legal obligations with The EU General Data Protection Regulation we would like to inform you that by completing our registration forms, Costello Yoga and Fitness will process your personal information to enable us to provide our services to you. We now seek your explicit consent that we may collect and process your personal information. You may withdraw your explicit consent (in writing) at any in the future. For further information on how we process your personal information please refer to our privacy statement on www.costelloyogaandfitness.com*
Do you suffer from, or have you in the past suffered from any of the following medical conditions? (Please tick as many boxes as needed)
Asthma
Epilepsy
Osteoporsis/Osteopania
Diabetes
Neck Injury
High Blood Pressure
Back Pain
Muscle Injury
Headaches/Migraines
Other (please specify)

Other (please specify)

In the last 5 years have you been admitted to hospital or had any medical procedure or surgery. Please provide details:

Do you suffer from any other medical condition not already referred to above?
Women Only:
Hysterectomy
Menopausal Challenges
Caesarean Delivery
Early Termination of Menses
Are you Pregnant?

Have you practiced yoga before and if yes, for how long?
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
In accordance with our legal obligations with The EU General Data Protection Regulation we would like to inform you that by completing our registration forms, Costello Yoga and Fitness will process your personal information to enable us to provide our services to you. We now seek your explicit consent that we may collect and process your personal information. You may withdraw your explicit consent (in writing) at any in the future. For further information on how we process your personal information please refer to our privacy statement on www.costelloyogaandfitness.com*
Do you suffer from, or have you in the past suffered from any of the following medical conditions? (Please tick as many boxes as needed)
Asthma
Epilepsy
Osteoporsis/Osteopania
Diabetes
Neck Injury
High Blood Pressure
Back Pain
Muscle Injury
Headaches/Migraines
Other (please specify)

Other (please specify)

In the last 5 years have you been admitted to hospital or had any medical procedure or surgery. Please provide details:

Do you suffer from any other medical condition not already referred to above?
Women Only:
Hysterectomy
Menopausal Challenges
Caesarean Delivery
Early Termination of Menses
Are you Pregnant?

Have you practiced yoga before and if yes, for how long?
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
In accordance with our legal obligations with The EU General Data Protection Regulation we would like to inform you that by completing our registration forms, Costello Yoga and Fitness will process your personal information to enable us to provide our services to you. We now seek your explicit consent that we may collect and process your personal information. You may withdraw your explicit consent (in writing) at any in the future. For further information on how we process your personal information please refer to our privacy statement on www.costelloyogaandfitness.com*
Do you suffer from, or have you in the past suffered from any of the following medical conditions? (Please tick as many boxes as needed)
Asthma
Epilepsy
Osteoporsis/Osteopania
Diabetes
Neck Injury
High Blood Pressure
Back Pain
Muscle Injury
Headaches/Migraines
Other (please specify)

Other (please specify)

In the last 5 years have you been admitted to hospital or had any medical procedure or surgery. Please provide details:

Do you suffer from any other medical condition not already referred to above?
Women Only:
Hysterectomy
Menopausal Challenges
Caesarean Delivery
Early Termination of Menses
Are you Pregnant?

Have you practiced yoga before and if yes, for how long?
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
In accordance with our legal obligations with The EU General Data Protection Regulation we would like to inform you that by completing our registration forms, Costello Yoga and Fitness will process your personal information to enable us to provide our services to you. We now seek your explicit consent that we may collect and process your personal information. You may withdraw your explicit consent (in writing) at any in the future. For further information on how we process your personal information please refer to our privacy statement on www.costelloyogaandfitness.com*
Do you suffer from, or have you in the past suffered from any of the following medical conditions? (Please tick as many boxes as needed)
Asthma
Epilepsy
Osteoporsis/Osteopania
Diabetes
Neck Injury
High Blood Pressure
Back Pain
Muscle Injury
Headaches/Migraines
Other (please specify)

Other (please specify)

In the last 5 years have you been admitted to hospital or had any medical procedure or surgery. Please provide details:

Do you suffer from any other medical condition not already referred to above?
Women Only:
Hysterectomy
Menopausal Challenges
Caesarean Delivery
Early Termination of Menses
Are you Pregnant?

Have you practiced yoga before and if yes, for how long?
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Do you consent to receiving emails from Costello Yoga and Fitness with regard to upcoming events, classes or any events we feel may be of interest to you? We would like to inform you that you can withdraw your consent (in writing) to receiving any of the above information at any time in the future?
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
How did you hear about us?
How did you hear about us?
Word of Mouth
Flyer
Website
Signage
Friends
Social Media
Other (Please Specify)

Other (Please Specify)
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
In accordance with our legal obligations with The EU General Data Protection Regulation we would like to inform you that by completing our registration forms, Costello Yoga and Fitness will process your personal information to enable us to provide our services to you. We now seek your explicit consent that we may collect and process your personal information. You may withdraw your explicit consent (in writing) at any in the future. For further information on how we process your personal information please refer to our privacy statement on www.costelloyogaandfitness.com*
Do you suffer from, or have you in the past suffered from any of the following medical conditions? (Please tick as many boxes as needed)
Asthma
Epilepsy
Osteoporsis/Osteopania
Diabetes
Neck Injury
High Blood Pressure
Back Pain
Muscle Injury
Headaches/Migraines
Other (please specify)

Other (please specify)

In the last 5 years have you been admitted to hospital or had any medical procedure or surgery. Please provide details:

Do you suffer from any other medical condition not already referred to above?
Women Only:
Hysterectomy
Menopausal Challenges
Caesarean Delivery
Early Termination of Menses
Are you Pregnant?

Have you practiced yoga before and if yes, for how long?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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