Registration Form Question Title * 1. What's your contact details? Name Address Address 2 City/Town ZIP/Postal Code Email Address Phone Number OK Question Title * 2. When's your birthday? Date Date OK Question Title * 3. What's your gender? Female Male Rather not say OK Question Title * 4. Who is your emergency contact (just in case)? Name: Phone number: OK Question Title * 5. How did you hear about Beautifully Balanced? From a friend A poster On Facebook On Instagram Hilton & Dove Valley Life Magazine The Etwall Express Magazine Unlimited Wellbeing Event Egginet Other (please specify) OK Question Title * 6. Which services are you interested in? Yoga classes Zumba classes Meditation classes Private Yoga Tuition Wellbeing Workshops OK Question Title * 7. What are your main well-being goal(s)? Select up to 3. Reduce stress Build confidence Lose weight Build strength Tone-up Socialise Time for yourself Switch mind off Improve fitness Increase flexibility Other (please specify) OK Question Title * 8. Do you currently have from any of the following that may impact you in class? None Low blood pressure High blood pressure Joint complaint Back problems Fracture/ sprain Arthritis Heart complaint Faint or dizziness Pregnant Given birth in the last 6 months Other (please specify) OK Question Title * 9. In relation to Q8, do you confirm that you have consulted with a healthcare professional about your ability to exercise and that you are fit to participate? I ticked 'None' in Q8 Yes No If Yes, please note relevant details, e.g. of any restrictions on your physical activities given. If No, please consult with a healthcare professional before you start classes. OK Question Title * 10. Declaration: *I have answered these questions to the best of my belief and know of no other reason why I should not partake in a course of exercise*If in any doubt, I understand that I should seek medical approval/advice before commencing classes with Beautifully Balanced*I will inform my instructor if my medical condition changes in the future*I understand that all exercise carries a risk of injury. I accept responsibility for my own body and I will stop if I experience any pain *I understand that the instructor will not be held responsible for any accident or injury. Yes No OK DONE