Name* First Last Email* Phone*Gender*Birthdate* Month Day YearAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Name* First Last Emergency Contact Phone*Health Conditions*I'm a New Student* Yes NoNew Student SurveyThis survey helps us learn about your general health and daily activities. The information that you provide will be kept confidential. We seek to understand Yoga Moves student needs, and how yoga affects MS, Parkinson's Disease, similar neuromuscular condition symptoms, and quality of life. Answer each question by checking the appropriate box or filling in the blanks.Does your current health affect the following?Range of motionNot at allA little bitModeratelyQuite a bitExtremelyFatigueNot at allA little bitModeratelyQuite a bitExtremelyStrengthNot at allA little bitModeratelyQuite a bitExtremelyStressNot at allA little bitModeratelyQuite a bitExtremelyAnxietyNot at allA little bitModeratelyQuite a bitExtremelyBalanceNot at allA little bitModeratelyQuite a bitExtremelyCognition (memory, concentration, etc.)Not at allA little bitModeratelyQuite a bitExtremelyAbility to walk short distancesNot at allA little bitModeratelyQuite a bitExtremelyFine motor coordinationNot at allA little bitModeratelyQuite a bitExtremelyAbility to go from seated to standing and vice versaNot at allA little bitModeratelyQuite a bitExtremelyPainNot at allA little bitModeratelyQuite a bitExtremelySleepNot at allA little bitModeratelyQuite a bitExtremelySocial ActivitiesNot at allA little bitModeratelyQuite a bitExtremelyHow would you rate your current quality of life?1 - Worst possible quality of life2345678910 - Best possible quality of lifeHave you ever practiced or participated in yoga and meditation? (If yes please describe your experience with yoga and mediation: Yes NoPlease describe:Why do you want to join Adaptive Yoga Moves Any Body classes? How do you think it can help you?Do you currently participate in any other organized fitness activities? Yes NoIf yes, how many times per week are they? 1 time 2 times 3 times or moreIf yes, are the classes in person or online? Yes NoDo you independently exercise home? Yes NoIf yes, how many times per week are they? 1 time 2 times 3 times or moreIf yes, what type of exercise is it?Do you have any injuries or health care conditions for which you are receiving medical care? Are you working with a clinician on these or any other health care challenges? (please explain)Do you walk with assistance, such as a cane, walker, scooter or wheelchair? (please explain)Please share anything you would like as us to know.The mission Yoga Move MS is to increase the quality of life for individuals with Multiple Sclerosis and neuromuscular conditions by providing yoga and mindfulness practices.Agreement* I have read the release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions.1. That I am participating in Yoga Classes offered by Yoga Moves MS (YMMS) during which I will receive information and instruction about yoga and health. I recognize that yoga requires physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. 2. In further consideration of being permitted to participate in yoga classes by YMMS, I knowingly, voluntarily and expressly waive any claim I may have against Mindy Eisenberg and Yoga Moves MS and YMMS instructors, for injury or damages that I may sustain as a result of participating in the yoga classes provided by YMMS. 3. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the yoga classes provided by YMMS. I represent that I am physically fit and I have no medical condition, which would prevent my full participation in the yoga classes. I agree that I am responsible for determining the extent of my abilities, and not exceeding them. 4. I understand YMMS may require the presence and assistance of a caregiver during YMMS classes. 5. I understand that I may receive hands-on adjustments in the classroom setting from YMMS instructors to correct position and/or alignment. If I do not want to receive such adjustments, or an adjustment has gone too far, I will advise the instructor at that time. 6. Regarding permission to use pictures and video recordings, I hereby give YMMS the absolute right and permission to publish, copyright and use pictures and videos of me in which I may be included in whole or in part, composite or retouched in character or form. I give permission to YMMS to use my name and guest’s names, photograph or video, likeness or other media of us from the event in any promotional materials, publications or via the website. 7. I understand that given the special nature of these classes and workshops, YMMS reserves the right to restrict or not allow participation due to safety concerns given my health or medical condition, but does not bear responsibility for assessing my health or medical condition. 8. I hereby release and hold harmless YMMS, it’s principals, officers and instructors, and all others connected with the sponsorship and conduct of these events for all injuries, claims, liability, damages and causes of action -- either at law or in equity -- which I may have or acquire, or which may accrue to me, my heirs, administrators, executors or assigns arising out of or connected in any way with my participation in and travel to and from such events. 9. I intend this to be a complete release and discharge of all persons as well as any corporate entities having anything to do with these events and I intend, hereby, to release harmless said persons and entities from all liability whatsoever.Your Signature*EmailThis field is for validation purposes and should be left unchanged.