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Pre-Natal Yoga

This five-week series of yoga classes taught by a certified yoga instructor will focus on deep-breathing techniques, stretching and strengthening exercises appropriate for moms-to-be and their babies.

$45/series of classes or $10/class

7 – 8 p

Dates:

Series 2 – June 2, 9, 16, 23 and 30

Series 3 – Oct. 20 and 27; Nov. 3, 10 and 17


Participants are asked to bring a yoga mat, water, pillow and two towels to class.

Additionally, a physician release is required. Please have your physician complete, and bring to the first class. Click here for Physician Consent Form - Prenatal Yoga


Marshall Women’s Health & Education Center
Norton Medical Plaza III – Suburban, Suite IA
4121 Dutchmans Lane



* Indicates required information
Name * 
Street Address 1 * 
Street Address 2 
City * 
State * 
Zip * 
Date of Birth  * 

Email Address
Email is how we will alert you to schedule changes, and will only be used for this purpose.

 * 
Phone (cell) * 
Phone (home) 
Physician * 
Due Date * 
Emergency Contact * 
Emergency Contact Phone * 
Relationship * 
Prenatal Yoga Screening  
Have you ever been told by your doctor that you have a heart condition and that you should only do physical activity recommended by a doctor or no physical activity? * 

Do you have pain in your chest when you do physical activity? * 

In the past month, have you had chest pain when you were not doing physical activity? * 

Do you lose your balance because of dizziness or do you ever lose consciousness? * 

Have you experienced vaginal bleeding or loss of fluid during this pregnancy?  * 

Do you have lower back or sciatic pain?  * 

Do you have a bone or joint problem that could be made worse by physical activity? * 

Do you currently take any medication for blood pressure or a heart condition? * 

Do you know of any other reason why you should not do physical activity? * 

Do you currently smoke? * 

Do you drink alcohol? * 

Do you have frequent headaches?  * 

Prior to your pregnancy, was there a pre-existing medical condition or other limitation that would affect your ability to participate in a yoga class? * 

Since your pregnancy, do you believe there is any current or pre-exiting medical condition or other limitation that may affect your ability to safely participate in a yoga class?  * 

Please list any prescribed medications you are taking: 
Medication 
Purpose 
Please read carefully and initial the following statements:  
I am fully responsible for the outcome of my yoga practice and participation in class. * 
I understand that I should report any problems with my pregnancy to my physician/midwife. * 
I will keep my yoga instructor informed with any changes in my pregnancy or physical health.  * 
RELEASE AND CONSENT 
I being aware of my own physical condition and the risks involved, am voluntarily participating in a prenatal yoga class. I hereby affirm that I do not suffer from any condition or disability that would prohibit my participation in this class. 
I fully understand that my participation in these activities may result in serious injury. 
I assume all risk’s connected therewith and consent to participate in said activities. 
Furthermore, I hereby release Norton Healthcare, as well as its instructors, agents, representatives, employees, contractors, successors and assigns, from liability for any injury or illness I may incur, now or in the future, as a result of participating 
in this class or as a result of negligent act or omission.  
I have read and understood, and agree to be bound by the above statement. * 

Electronic Signature * 
Date *  (mm/dd/yyyy)
What Dates would you like to attend? * 











Payment Information
Amount
Credit Card Type* 
Credit Card Number* 
Card Verification Code* 
Name as it appears on card* 
Expiration Date*  Month Year
Address* 
Address 2 
City* 
State* 
Zip* 
Authentication * 

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