Waiver & Release Form
Personal Information
Emergency Contact
Previous Experience
- Word of Mouth
- Physical Advertising e.g. flyer, sign
- Other
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Medical History
- Heart Condition
- Musculoskeletal Pain
- High BP
- Low BP
- Diabetes
- Pregnant - please provide further details below
- Postnatal - please provide further details below
- Asthma
- Post-Surgical - please provide details below
- Joint Problems e.g arthritis
- Neurological Disorder
- Back Pain
- Other - please provide details below
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- Yes
- No - please provide details below
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Prenatal Students Only
- Yes
- No
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- Vaginal
- C-Section
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- Yes
- No
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- Fluid Retention
- Leg Cramps
- Aching Hips
- Heart Burn
- Nausea
- Insomnia
- Other - please explain
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Ensure you update your teacher of any changes throughout your pregnancy that may affect you during class.
Postnatal Students Only
- Vaginal
- C-Section
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- Prolapse
- Abdominal Separation (diastasis recti)
- Incontinence
- Excessive Bleeding
- Perineal Pain
- Pain at the incision site if c-section was performed
- Postpartum infections
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- Yes - provide details below
- No
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I run a monthly mum's meetup in Singleton. Go to events on my website for details and to join our private Facebook group.
I highly recommend all postpartum women attend an appointment with a women's health physiotherapist, especially if you have ticked any of the above options. Speak to me if you would like some recommendations.
If you think you may be experiencing postpartum anxiety or depression, please see your doctor for a mental health care plan.
Helpful Resources:
Pregnancy, Birth & Baby: A government run hotline where you can talk to trained specialists about anything from pregnancy to preschool on 1800 882 436 or a video call.
PANDA (Post and Antenatal Depression Association Inc.): Provides free telephone support, counselling and information on antenatal and postnatal depression on 1300 726 306 and helpful information on their website.
beyondblue: The national depression and anxiety initiative provides a support service to talk with a health professional on 1300 224 636 as well as email or chat through their support service.
Tresillian: An early parenting service offering guidance in the early years of a child’s life. Support includes around topics such as breastfeeding and settling baby, as well as dealing with postnatal depression and nutrition. Tresillian can be reached at 1300 272 736 or via online support.
SANDS: Provides information via their website and confidential 24/7 support by trained supporters who have a personal understanding of the grief and confusion that may be experienced following miscarriage, stillbirth or death of a baby which can be reached on 1300 072 637 or via online chat.
* Resources taken from cope.org.au
Agreement
If you are under 18 years of age, you must have a parent or guardian sign this form.
I understand that the instructions given throughout classes are intended only as guidance only. If at any time I feel pain or strain, I will gently come out of the posture and take rest. I understand that it is my responsibility to:
1. Adjust the practice according to my limitations to ensure no personal injury occurs.
2. Inform the teacher before my class of any recent changes to my physical condition.
I understand and acknowledge that yoga/Pilates is not a substitute for medical attention or treatment and my yoga/Pilates instructor is not able to provide medical advice.
The information I have provided in this form is used only as a guide to determine the limitations of my ability to undertake a yoga/Pilates practice.
VALLEY FLOW recommends that medical approval be obtained before commencing yoga/Pilates practice. I acknowledge that YOUR YOGA SPOT will not be held responsible for any neglect on my behalf to seek medical approval before commencing yoga/Pilates practice.
I hereby declare that I release VALLEY FLOW of any responsibility for any damage to person or property incurred as a result of my participation in yoga/Pilates practice with VALLEY FLOW. I will take full responsibility for myself and my personal property during yoga/Pilates classes.
*All information collected by Valley Flow will be kept strictly confidential. Valley Flow will not share any of your personal information with any third party.
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