NurtureWorks Yoga & Qigong Registration Form

NurtureWorks Qigong Class Registration Form

Please answer what's relevant. And keep your answers concise - while letting me know any key facts that I (as your teacher) need to know about your health.

Thanks for sharing your personal data. The information helps keep my classes safe, enjoyable and beneficial for all.

NurtureWorks is committed to safeguarding your privacy. I'll never share your data with third parties for marketing purposes. Your health data will be kept strictly confidential. See my Privacy Policy.

NurtureWorks Qigong Class registration

First Name *

Surname *

Date of birth *

Email *

Address

Post Town/City

County

Postcode

Phone

Doctor's name & address

Doctor's Phone

Where did you hear about NurtureWorks? *

Would you like to receive NurtureWorks' occasional email updates? (News about upcoming workshops and class-change alerts? You can unsubscribe any time) *

Yes

Qigong etc

Have you practised Qigong before? What whom? For how long?

Have you practised other Chinese internal or martial arts, Yoga, somatic movement, meditation etc? If so, what? For how long?

Do you take regular exercise? What?

What do you hope to get from your Qigong practice?

Health and Medical Conditions

Please give relevant details of any health issues or medical conditions

Women's Health

Please give as little or as much information as you wish.

Do you suffer from any menstrual cycle or gynaecological pain or issues?

Yes

Are you pregnant?

Yes

Please give any additional details of any of the above or other issues here

Medications etc

Are you taking any medicine or natural remedies? Please give details? Do you suffer any side effects?

Have you consulted your GP before starting Yoga/Qigong? (in cases of health issues)

Yes

Some guidelines

PLEASE:

Try not to eat for at least 2 hours before class. If impossible, please eat lightly.
Wear comfortable clothes you can move easily in
Wear spacious, flexible shoes. Or you can practise barefoot.
For in-person classes, I have Yoga mats and other equipment. Feel free to bring your own mat if you wish.
Try to arrive 5-10 minutes before class. If you are held up, please enter quietly.
Turn your mobile phone off before the class starts.

Declaration

I declare that the information I have given here is correct and that as far as I am aware I can participate in Qigong classes without any adverse effects.
I understand it is my responsibility to inform my teacher of any injury or change in my health.
I understand that, should I have any concerns, I should consult the teacher before continuing, and my GP if required.
I understand that I should inform my teacher if I am uncomfortable or in pain during or after the class.
I am aware that occasional hands-on adjustments may be made in in-person classes and give my consent.
I consent to Nurtureworks processing and storing (in accordance with its Privacy Policy) the personal health data that I have given above to help improve customer experience by keeping classes safe and relevant to student needs.

Please tick *

I confirm I agree with the above declaration

Did you sign up and pay for my 4-week Qigong class trial?

Yes

If you are human, leave this field blank.