Young Yogi Intake Form

Please fill out the form below to help us serve you and your child better.

Child's Name*
First Last
Parent's Email Address*
Enter Email Confirm Email
Child's Email Address
if applicable
Enter Email Confirm Email
Child's Birthdate*
Child's Gender*
Parent's Name*
First Last
Parent's Phone Number*
Additional Phone Number
Child's Address*
Street Address Address Line 2 City State ZIP Code
Emergency Contact Name*
different from listed parent
First Last
Emergency Contact Relationship*
Emergency Contact Phone*
Has your child ever practiced yoga?*
- Yes
- No
Medical Alert*
(conditions, injuries, physical limitations, special needs, diagnosis, or medications/side effects). If not applicable, please state N/A
What are your yoga goals for your child?*
How does your child act in social settings?*
What triggers your child?*
How does your child respond to touch?*
What comforts your child?*
What are your child's strengths? What are your child's areas of concern?*
Please share any other relevant information to allow us to best support your child during class.*
Consent*
All exercise programs involve a risk of injury. By choosing to participate in Breathe Grace Yoga classes you voluntarily assume the risk of injury. The following guidelines will help you reduce your risk of injury, but they are not guaranteed to eliminate all risk. Listen to and follow instructions carefully. Breathe smoothly and continuously as you move and stretch. Avoid straining to attain any position. Work gently, respecting your body’s abilities and limitations. Avoid postures or movements that are painful. Ask questions if you are unsure how to perform a certain movement or if you need a modification. Breathe Grace Yoga and Erin Cuomo are responsible for providing competent yoga instruction, but not for ensuring the safety of students. By signing this form, you hereby release Breathe Grace Yoga and Erin Cuomo from any and all liability for injuries or accidents that may occur as a result of your participation in yoga. Please check the box below if you agree to this consent.
I agree.

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