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KATE TITTLEY

Yoga teacher

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Fear & Loathing Off The Yoga Mat
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New Client Health Declaration

First Name

Last Name

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Date of Birth

Do you have a doctor’s permit to participate in intense physical activities?

No

Yes

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I declare that the info I’ve provided is accurate & complete

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

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