form - Synergy Yoga Centre

Blank Form (#4)

Reg no

Registration Date

(A) PERSONAL INFORMATION: (STUDENT)

Student Name

Date Of Birth

Blood Group

Occupation

Gender

Male

Female

ID-Proof

ID-Number:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

(B) EMERGENCY CONTACT DETAILS:

Parent/Guardian Name

Phone/Mobile

(C) YOUR GOAL:

What is your goal to be achieved through YOGA:

(D) PHYSICAL & MENTAL FITTNESS:

Student Name:

Age

Weight in Kgs

Height in cms

Have you practiced yoga before?

Yes

How long?

Do you have any Mental Disabilities?

Yes

Explain it here

Do you have any Problems in Speaking / Hearing / Listening?

Yes

Explain it here

Medical History: Please tick all relevant conditions applicable to student.

Provide Medical History Details

Have your suffered any Injuries (or) under gone any recent surgeries (or) any other Limitations that may restrict in doing physical exercises / movements or yoga practice?

Yes

Textarea

Are there any other medical or special considerations?

Yes

Provide details

I/We declare and confirm that the medical history given above is true.

(E) PREGNANCY DETAILS:

Are You Pregnant

Yes

Due date

Last Child Birth Date:

As on date of joining, Pregnancy Weeks (or) Post Delivery Weeks

Have you had any complications with previous pregnancies or history of miscarriage?

Yes

If so, provide details

Does your family have a history of any of the conditions above?

Yes

If so, provide details

Doctor Name:

Hospital Name:

(F) DECLARATION: (STUDENT & PARENT/GUARDIAN)

Checkbox Field

I/We declare that, I/We am/are joining "SYNERGY YOGA CENTRE" at my /our own interest and risk to practice yoga, to keep myself fit and healthy.

I /We have read the Terms & Conditions given below in the Registration form and I /We hereby give our unconditional acceptance towards the same.

I /We understand that, any misbehavior or any misconduct during the yoga sessions, will leads to disciplinary action, it may extend including revoke of the admission given and fees paid, if any will be fortified.

I/We also understand that "SYNERGY YOGA CENTRE" or its management is responsible only for informing the Emergency Contact Person as per the details given in Section-B of this Registration Form, in case of any accidents or medical emergencies or any mishaps for the students.

Terms & Conditions

1. If at any time during the class, if you feel discomfort or strain, gently come out of the posture.
You may rest at any time during the class. It is important in yoga that you listen to your body and
respect its limits on any given day.
2. I recognize that it is my responsibility to notify my teacher regarding any serious illness or
injury before every yoga class. I will not perform any posture to the extent of strain or pain.
3. Synergy Yoga Centre conducts yoga sessions in two types of batches, (1) Unisex and (2) Ladies
batch on Weekdays between Monday to Friday with the strict batch timings.
Batch No: Start Time End Time Batch type
1 6:00 am 7:00 am Unisex
2 7:00 am 8:00 am Unisex
3 5:00 pm 6:00 pm Ladies
4 6:00 pm 7:00 pm Unisex

4. Rights of Admission is Reserved and Acceptable at the discretion of the Synergy Yoga Centre
Management. And admission can be revoked at any time without assigning any reasons.
Amendments to the Terms and Conditions is applicable as per the discretion of the Synergy Yoga
Management and accepted by students.
5. Fees Can be paid on Monthly or Quarterly Basis, based upon the selected Packages. Fees Paid
are Non-Transferable, it is only applicable to Specific Student and Specific period (month or
Quarter). In Case of Change of Packages, it will be effective from next cycle of the chosen period
only (either next month or next Quarter)
6. Fees needs to be paid on or before 5th of Every month, if 5th is Weekend or Holiday, following
weekday will be due date. Fees paid beyond 5th will attract a Late Fee of Rs 100/- per day.
7. Fees Paid Once will not be refunded under any Circumstances.

Checkbox Field

I /We have read the above Terms & Conditions and giving my/our acceptance.

Student Name

Submit Date

Signature

Choose File

Parents / Guardian Name

Submit Date

Signature

Choose File

Synergy Yoga Centre

(A) PERSONAL INFORMATION: (STUDENT)

(B) EMERGENCY CONTACT DETAILS:

(C) YOUR GOAL:

(D) PHYSICAL & MENTAL FITTNESS:

(E) PREGNANCY DETAILS:

(F) DECLARATION: (STUDENT & PARENT/GUARDIAN)

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