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Referral Form
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A Yoga Adventure
a Yoga Adventure Order Form
Glow Yoga Kids Subscription Boxes
Glow Yoga Kids Subscription Boxes Order Form
YOGA CLIENT INTAKE FORM – CONFIDENTIAL INFORMATION
We would like to make your child’s yoga experience with Glow Yoga Kids as effective and enjoyable as possible. Providing specific details about your child will assist us greatly in this process. If at any time you have questions regarding our sessions, please let us know!
CONTACT DETAILS
*
Indicates required field
Student Name
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First
Last
Date of Birth
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Current Age
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Gender
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Female
Male
Parent Name
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First
Last
Parent Main Phone Number
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Parent Cell Number (if different)
*
I give permission for Glow Yoga Kids to send me any urgent updates via text message
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Yes
No
Address
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City
*
Province
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Postal Code
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Parent Email Address
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I wish to receive updates about current and future programs via email
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Yes
No
Emergency Contact (aside from parent)
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Emergency Contact Phone Number
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YOUR CHILD/ YOU
Has you or your child ever practiced yoga before?
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Yes
No
Medical Alert (conditions, injuries, physical limitations, special needs, diagnosis, or medications/side effects). If not applicable, please state N/A
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What weekly program are you registering for?
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Online Yoga for my daycare
Online Yoga for my school
Online Yoga for my home
Virtual Classes- Ages 3-5
Virtual Classes- Ages 1-2
Virtual Classes- Hearing impaired/ Speech Delayed Ages 3-5
Virtual Classes- Mom and Baby
Virtual Classes- Ages 6-12
Virtual Classes- Additional Needs
Virtual Classes- Ages 13-17
Virtual Classes- Family yoga- All Ages
Virtual Classes- Yin/ Restorative
What are your goals for your child within this yoga program?
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Strength
Flexibility
Balance
Stress relief
Concentration/Focus
Coordination
Increased body awareness
Address specific health concern
Boost self esteem/confidence
Other
Please explain other if applicable
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Please assist us in how to best work with your child's individual needs; answer to the best of your ability!
How does your child act in social settings?
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What triggers your child?
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How does your child respond to touch?
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What comforts your child?
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What are your child's strengths? Areas of concern?
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Please share any other relevant information to allow us to best support your child during class.
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The personal information collected on this form is in order to establish a client’s identity and to assist our teachers in providing the finest instruction and classroom environment for your child. All information will remain private and confidential.
I, the parent or legal guardian of
Student's Name
*
a minor, understand that yoga includes individual physical movements, supportive touch, group work as well as an opportunity for relaxation, stress reduction, and relief of muscular tension. I declare that my child is physically able and ready to participate in the Glow Yoga Kids program. I understand that Glow Yoga Kids will take all reasonable care to ensure that the classes are safe. However, as is the case with any physical activity, the risk of injury, even serious or disabling, is always present and can not entirely be eliminated. If my child experiences any pain or discomfort, my child will listen to his/her body, adjust the posture and ask for support from the teacher or practitioner. Yoga is not a substitute for medical attention, examination, diagnosis, or treatment. I affirm that I alone am responsible to decide whether my child practices yoga.
I hereby agree to irrevocably release and waive Glow Yoga Kids to any claims that I have now or hereafter may have against any and all Glow Yoga Kids Instructors. I have read and fully understand the above agreement terms and it is expressly agreed that Robyn Snow, Glow Yoga Kids and it’s agents and independent contractors shall not be held liable for claims, demands, injuries, damages, actions or causes of action, whatsoever, to my child or property arising out of or connected with the yoga program or due to a pre-existing condition not disclosed by myself or other persons responsible for my child. My digital signature below states my full acceptance and concurrence with the terms of this agreement.
Parent Full Name
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Date
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Glow Yoga Kids has the goal to promote kids yoga within our community and city, therefore we use a website, social media accounts and paper/electronic advertisements to assist in achieving this goal.
I give my permission for Robyn and Glow Yoga Kids to use my child’s image (photo or video) for online and print promotions of kids yoga and teaching seminars. My child will not be identified in any way.
Child's Full Name
*
First
Last
Parent's Full Name
*
First
Last
Date
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Thank you for taking the time to fill out this form! We look forward to serving you and your children in a loved-up and joy-filled manner.
I agree to receiving marketing and promotional materials
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