Registration Form - Yoga Centric

Vitality Junction Health Centre
179 Union St The Junction
15 May – 26 June
Wednesdays 9.15-10.30 am
$140 (includes morning tea)

Can’t make these dates? Register your interest in our upcoming courses – click here

The River is Flowing – Registration Form

For women with mental health challenges

Your Details

Name(Required)

First Last

Date of birth(Required)

Address(Required)

Street Address Address Line 2 Suburb Post Code

Phone(Required)

Email(Required)

Emergency Contact

Name(Required)

First Last

Relationship(Required)

Phone(Required)

Yoga and Health History

Have you done Yoga before?(Required)

Never

Beginner

Intermediate

Type of Yoga Practised Previously(Required)

If you don’t know -just put N/A

How did you hear about our course?(Required)

Any pre-existing injuries or medical conditions?

High Blood Pressure(Required)

Yes

Back problems(Required)

Yes

Low Blood Pressure/Fainting(Required)

Yes

Neck problems(Required)

Yes

Arthritis(Required)

Yes

Knee problems(Required)

Yes

Diabetes(Required)

Yes

Immune issues or autoimmune disease including allergies(Required)

Yes

Epilepsy(Required)

Yes

Mobility issues(Required)

Yes

Heart Problems(Required)

Yes

Digestive/Gut problems(Required)

Yes

Asthma or other respiratory issues(Required)

Yes

Recent pregnancies(Required)

Yes

Detached retina or other eye problems e.g. glaucoma(Required)

Yes

Are you pregnant?(Required)

Yes

Recent fractures or sprains(Required)

Yes

Number of weeks pregnant(Required)

Please enter a number from 1 to 42.

Recent surgeries(Required)

Yes

Other(Required)

Yes

For any questions you answered Yes to, can you please provide some more details:(Required)

You indicated "Other" above, can you please porvide more details:(Required)

Do you have any mental health or neurological conditions?

This course will support you with your particular mental health condition/challenges.

Anxiety(Required)

Yes

PTSD(Required)

Yes

Depression(Required)

Yes

Panic Attacks(Required)

Yes

Bipolar(Required)

Yes

Traumatic Brain Injury(Required)

Yes

Schizophrenia(Required)

Yes

Cognitive or learning issues(Required)

Yes

OCD(Required)

Yes

Stroke(Required)

Yes

Addiction(Required)

Yes

Self-Harm(Required)

Yes

Please advise what addiction(s) you are dealing with:(Required)

Personality Disorder(Required)

Yes

Suicidal Ideation(Required)

Yes

Eating Disorder(Required)

Yes

Other(Required)

Yes

You indicated "Other" above, can you please provide more details?(Required)

Do you have Neurodivergence such as Autism Spectrum Disorder or ADHD?(Required)

Yes

Please list any medications you may be on here:(Required)

Just put N/A if you are not taking any medications.

Important

Welcome to The River is Flowing program. The following information will help you get the most out of your sessions and help you understand the role of the Yoga instructor.

We are certified Yoga instructors with Yoga Australia and have completed a thorough professional training in Yoga instruction. In your practice, please listen to your body and how you feel on the day and modify for any recent injuries or issues.

All exercise involves a risk of injury. By choosing to participate in Yoga classes, you voluntarily assume a certain risk for injury. The following guidelines will help you reduce your risk of injury.

Listen to and follow instructions carefully
Breathe smoothly and continuously as you move and stretch
Do not hold or strain your breath
Work gently, respecting your body’s abilities and limits
Do not perform postures or movements that are painful
Ask if you are unsure of how to perform a certain movement
Pregnant women must consult their healthcare provider before enrolling in the course

It’s always advisable to consult your doctor before embarking on any exercise program including Yoga. Please advise the teachers if any new health conditions or injuries arise or if there is any change in your mental health.

Awareness if fundamental to the practice of Yoga. It is your responsibility to monitor each activity and determine whether it’s appropriate for you to participate. You remain primarily responsible for your safety and well-being.

As a professional, your instructor is responsible for providing competent Yoga instruction. Your instructor is not responsible for ensuring the safety of students beyond providing competent instruction. By signing this form, you hereby release your instructors from any and all liability for injuries that are not directly and proximately caused by professional negligence.

Please confirm(Required)

I have read, understood and agree to the content of this Professional Disclosure and Release Form.

Are you happy to receive emails from us regarding upcoming courses?(Required)

Yes

Full Course – 7 weeks(Required)

Price:

Includes morning tea and resources

Signature – Please Sign(Required)

Use your mouse or finger to sign.

Total Registration Fee

No refunds are available for unused classes but you may transfer these to a friend upon approval

Credit Card

Phone

This field is for validation purposes and should be left unchanged.