Student Registration Form Status* New Student Existing Student Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneEmail* Class Preference*Relax and RestoreCore SupportHealth InformationHealth ConditionsAny condition that you feel might interfere with your Yoga, please talk to your instructor. Please check any health conditions that apply to you (past or present): *Heart Disease *High Blood Pressure Low Blood Pressure Migraines Stress Headaches Sinus Low Back Pain Neck/Shoulder Cancer Stroke Menstrual Discomfort Carpal Tunnel Arthritis Fibromyalgia/Chronic Fatigue Glaucoma Seizures Pregnancy Broken Bones Recent Surgeries (2 years) Other Health Concerns Pregnancy Week #* Broken Bones* List Surgeries From Past 2 Years* List Any Other Health Concerns*Prenatal InformationExpected Delivery Date* MM slash DD slash YYYY Physician/Care Provider* Health Details *Gestational Diabetes *High Blood Pressure *Placenta Previa *Bleeding *Twins Low Blood Pressure Anemia Client Liability Waiver*Must have permission from your physician to participate.03/19/2024 I understand that these activities include physical movements as well as an opportunity for relaxation, stress reduction and relief of muscular tension. As is the case with any physical activity, the risk of injury is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body and ask for support from the teacher. When necessary, medical attention, examination, diagnosis and treatment are recommended. I affirm that I am responsible to decide whether or not to attend class. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against 2B Well, LLC and 2B Well affiliates.Name* First Last Your Signature