Victoria Yoga

Click here for Private Yoga Training details

You can either print our Private Training Form and send us, or fill the online form below to inquire for private training.

Thank you for taking the time to tell me about yourself. The information you have provided will help me personalize your next yoga experience.

The information you provide in your Personal Profile form will be kept in the strictest confidence. Please be specific as possible omitting any section necessary.

RELEASE & WAIVER OF LIABILITY

I agree to the following:

1. The information I have provided below is complete and accurate.
2. I understand that I am participating in yoga training offered by VictoriaYoga.com, during which I will receive instruction about yoga, health and wellness. I recognize that yoga requires physical exertion that can be strenuous. I am fully aware of the risks involved.
3. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in yoga conditioning. I represent and warrant that I am physically fit and have no medical conditions that would prevent me from participation in yoga conditioning sessions. I assume full responsibility for any injuries or damages, known or unknown, which I might incur as a result of participating in yoga training. I knowingly, voluntarily, and expressly, waive any claim I may have against VictoriaYoga.com and any instructors for injury or damages that I may sustain as a result of participating in the program.

By submitting the form below, you agree to the terms and conditons above.

General Information

First Name:

Last Name:

Address 1:

Address 2:

Province/State:

Home Phone:

Work Phone - Ext:

Mobile Phone:

Email:

Website:

Date of Birth

monthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

day12345678910111213141516171819202122232425262728293031

Gender: select...MaleFemale

Mailing List: * select...YesNo

Can we add you to the mailing lists for occasional announcements and updates?

Emergency Contact

Emergency Contact Name:

Relationship to you:

Emergency Contact Phone:

How did you hear about private training with Chris or Michelle?:

My Private Training

I am interested in: select...private traininggroup trainingpower yogamens yogahatha yogapranayama yogafamily yogapre-natal yogapost-natal yoga

Days per week: select...1234567

How many days a week would you like to train?

What days of the week are best for you?: MondayTuesdayWednesdayThursdayFridaySaturdaySunday

In order to select multiple days, hold down "Ctrl" and select the days you prefer

For what time of day?: select...Between 7 am - 9 amBetween 9 am - 11 amBetween 11 am - 1 pmBetween 1 pm - 3 pmBetween 3 pm - 5 pmBetween 5 pm - 7 pmBetween 7 pm - 9 pm

What is your main purpose for scheduling private training?:

What would you like to achieve/experience through yoga private training?:

Personal yoga routine?:

Would you like a personal yoga routine created for you to review when you are practicing without an instructor?

Which of your hands is dominant for writing?:

And if you play a sport that requires sidedness (e.g., batting, & throwing in baseball, golf swing) please describe and indicate your dominant side.

SPORTS/MEDICAL HISTORY

Yoga experience level: select...noviceintermediateadvance

If experienced, please describe:

Do you play any sports?: select...YesNo

If yes, please specify:

Do you sit at a desk during the day?: select...YesNo

If yes, how many hours?:

Describe your physical activity on a typical weekday:

Describe your physical activity on a typical weekend day:

Do you belong to a gym?: select...YesNo

If yes, which one:

Do you train with weights?: select...YesNo

If yes, describe your weight-training goals and program, including how often you train and what body parts you work:

Do you participate in cardiovascular activity as part of your training?: select...YesNo

If yes, what type and how often?:

Are you affected by any of the following

Heart problems of any type?: select...YesNo

High Blood Pressure?: select...YesNo

Glaucoma?: select...YesNo

High blood pressure: select...YesNo

Greater than 140/90?

Depression?: select...YesNo

Arthritis: select...YesNo

or another bone or joint problem?

Diabetes?: select...YesNo

Any other disease or health condition not listed above?: select...YesNo

Pregnancy?: select...YesNo

If yes, please describe:

Are you currently taking any medications?: select...YesNo

If so, what ones?:

Do you take vitamins and/or supplements?: select...YesNo

If yes, please list:

Have you ever had surgery?: select...YesNo

If so, list what type(s) and when:

Have you ever broken a bone?: select...YesNo

If so, list the bone(s) and when:

Do you have any physical abnormalities or medical conditions other than those mentioned above?:

Please explain any health problems you have, medications you take, including dosages and therapies you are undergoing:

Consumption of

Alcohol (times/week):

Caffeine (times/week):

Nicotine/Tobacco times/week:

Other (times/week):

Do you have any children?: select...YesNo

If yes, how many?: select...12345+

Yoga Training History (if applicable)

Have you ever worked privately with a yoga teacher before?: select...YesNo

If yes, name of the teacher:

If yes, for how long (months):

General Comments:

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