1. College of Western Idaho
Yoga
Instructor: Barbara Harris
2012
Yoga is, among other things, a physical endeavor. The instructor will be able to make
adjustments with props and alternative poses to accommodate normal day to day issues
and minor physical restrictions. However, if you need major accommodations to complete
this class you will be referred to the Student Services area for assistance. The following
information will help the instructor to assist you with your practice and assure your safety.
If you prefer to discuss issues directly with the instructor or with Student Services please
let me know on the first day of class
Student Name:
Date
Have you had previous instruction in Yoga?
If yes when and how long did you study
Are you currently involved in a regular exercise program?
What kind of program
How often do you participate in this activity (xs/per week)
Do you have any of the following chronic medical condition?
__Allergies Do you carry an Epi Pen______
__Chronic back problems Please explain the nature of the problem
__Detached Retina Other____________________
__Glaucoma
Explanation:
Are you currently under the care of a physician for a specific issue?
Explain:
Do you take any medication on a regular basis?
Have you had a serious injury that causes reoccurring pain or weakness?
Are you currently dealing with an injury? ( Even if a minor injury if it will restrict your mobility)
What kind of injury
When did it occur?
Have you had surgery in the last 18 months?
What kind of surgery
When did it occur?

2. Name
Page #2
Are you pregnant? What is your expected delivery date?
If you are pregnant you should wait until after your delivery to take Beginning Yoga. Your
safety and the safety of your child is our up-most concern.
If you become pregnant during the semester, you will need to consult your physician about
continuing participation in a yoga class. You should explain to him/her that Iyengar Yoga is
very physically demanding , it is not “sitting and breathing” and can have a profound effect on
the entire body. Written consent from the physician will be needed so you can continue the
class. Modifications will be made as your pregnancy progresses. Please inform the instructor as
early as possible of your condition changes in hormone levels can make the body more
vulnerable to injury.
Is there ANY reason that you will not be able to participate in class and complete the required
activities of this class?YES_____________NO___________________
Is there any other information you think would be helpful for the instructor to know to help you
have a better experience in the yoga class?
Female students should inform the instructor prior to the beginning of class on days of
maximum menstrual flow. If you are in the beginning or the end of you cycle and flow is
minimal your participation will not be restricted. There are poses that are contra-indicated for
menstruating women in maximum flow. Accommodations will be made discreetly.
If you have painful menstruation please let me know, I will provide accommodations for your
pain.
Any student who comes to class not feeling well, please inform the instructor, accommodations
can sometimes be made to assist you. If you think you could be contagious……. Stay home
I have been informed of the physical nature of yoga and I understand my responsibility to inform
the instructor of any physical injuries or illnesses prior to participation in any class. I understand
that I am ultimately responsible for my own safety.
Signature:_____________________________________________________________________
Date________________