Health Questionnaire and Privacy

Zoe Marciniak (Life Yoga) takes your privacy seriously.

For online classes,  you’re welcome to complete the medical form below but if you prefer,  if you have any medical issues etc, please use the Chat function before the class (just to the Host) and the class can then be adapted. If you need a rest or feel that a pose isn’t for you, please listen to your body. It is difficult to teach from afar (you cannot be observed in the same way as an In Person class) so please listen to your bodies. You should understand that the teacher cannot be held responsible for any injuries or increased suffering from any medical conditions you may have – from your decision to undertake yoga practice and moving in ways that disagree with your body. Please respect your bodies, approach yoga with a compassionate mind, listen to the signals and take care.



Name :                             ………………………………………………………………………

 Email :                             ………………………………………………………………………

 House number and postcode:              ………………………………………………….

Mobile Phone :               ………………………………………………………………………..

 Next of kin contact :                          ………………………………………………………


In participating in the yoga classes and somatic classes / workshops or any other exercise programmes offered by Zoe Marciniak (Life Yoga) you will receive information and instruction about yoga, somatic movement, physical exercise or health.

You recognize that exercise requires physical exertion, which may be strenuous an may cause physical injury, and you are fully ware of the risks and hazards involved.

You understand that it is your responsibility to consult a physician prior to and regarding your participation in the yoga classes/ somatic yoga classes / workshops and health programmes offered by your instructor or substitute teacher.  You represent and warrant that you are physically fit and are physically fit and have no medical condition, which will prevent your participation in theyoga classes/ somatic yoga classes / workshops or health programmes.  You will disclose verbally any medical conditions prior to class so that adjustments can be made to class plans.  It is down to you to manage your condition within the class and participation in classes with any known conditions is at your own risk.

If you are pregnant you understand that you participate fully at your own risk and that of your unborn child/children.

In consideration of being permitted to participate in the yoga classes / workshops or health programmes, you agree to assume full responsibility for any risks, injuries or damages known or unknown, which you might incur as a result of participating in the classes / workshops or health programmes offered by your instructor or substitute teacher.

In further consideration of being permitted to participate in the yoga classes/ somatic yoga classes / workshops or health programmes, you knowingly, voluntarily and expressly waive any claim you may have against your instructor or substitute teacher for any injury or damages that you may sustain as a result of participating in these programmes.

You understand that from time to time during classes, the instructor may physically adjust students’ form and posture.  If you do not want such physical adjustments, you will so inform the instructor at each class you attend.  You also acknowledge that if you do wish to receive such adjustments, it is your responsibility to inform the instructor when it has gone as far as you desire at that time.

You hereby take full and sole responsibility from any liability or loss or damage to personal property associated with yoga classes or any other events.

You have read the above and release and waiver any liability and fully understand its contents and voluntarily agree to the terms and conditions stated above under your own free will.



Sign and print out / copy into email and email to

…………………………………………. Date


From time to time Zoe Marciniak may need to contact you about class scheduling (if you are attending classes).

Would you like to be kept informed about yoga classes (scheduling, new classes, venue changes etc) and any workshops that Zoe Marciniak (Life Yoga) may run in the future?


From time to time (very rarely) – I may send you data about a third party – for example a product or a workshop / service…


All emails and phone numbers will be stored in a passworded device and any paper forms handed in will be stored in a locked box.  You are welcome to contact me at any time to say you no longer wish to receive updates from me and your contact details and forms will be removed / shredded.

In selecting to receive information and updates from Zoe Marciniak (LifeYoga) you are agreeing to the Privacy Policy below.


This privacy policy sets out how Zoe Marciniak / Life Yoga uses and protects any information that you give Zoe Marciniak / Life Yoga when you use this their services or this website. Zoe Marciniak / Life Yoga is committed to ensuring that your privacy is protected. Should we ask you to provide certain information by which you can be identified when using their services or this website, then you can be assured that it will only be used in accordance with this privacy statement. Zoe Marciniak / Life Yoga may change this policy from time to time by updating this page. You should check this page from time to time to ensure that you are happy with any changes. This policy is effective from 03/05/2018.

What we collect

We may collect the following information:

  • name
  • contact information including email address
  • basic health information

What we do with the information we gather

We require this information to understand your needs and provide you with a better service, and in particular for the following reasons:

  • Internal record keeping
  • Emergency contact of lesson attendees.
  • We may use the information to improve lesson plans.
  • We may periodically send promotional email about new lessons, special offers or other information which we think you may find interesting using the email address or text which you have provided.


We are committed to ensuring that your information is secure. In order to prevent unauthorised access or disclosure we have put in place suitable physical, electronic and managerial procedures to safeguard and secure the information we collect online.

How we use cookies

A cookie is a small file which asks permission to be placed on your computer’s hard drive. Once you agree, the file is added and the cookie helps analyse web traffic or lets you know when you visit a particular site. Cookies allow web applications to respond to you as an individual. The web application can tailor its operations to your needs, likes and dislikes by gathering and remembering information about your preferences.

We use traffic log cookies to identify which pages are being used. This helps us analyse data about web page traffic and improve our website in order to tailor it to customer needs. We only use this information for statistical analysis purposes and then the data is removed from the system.

Overall, cookies help us provide you with a better website, by enabling us to monitor which pages you find useful and which you do not. A cookie in no way gives us access to your computer or any information about you, other than the data you choose to share with us.

You can choose to accept or decline cookies. Most web browsers automatically accept cookies, but you can usually modify your browser setting to decline cookies if you prefer. This may prevent you from taking full advantage of the website.

Links to other websites

Our website may contain links to other websites of interest. However, once you have used these links to leave our site, you should note that we do not have any control over that other website. Therefore, we cannot be responsible for the protection and privacy of any information which you provide whilst visiting such sites and such sites are not governed by this privacy statement. You should exercise caution and look at the privacy statement applicable to the website in question.

Credit card details

We do not take electronic payments using card data collected from you.  If you pay by Bank Transfer (using your own bank software), no loss or liability can be accepted by Zoe Marciniak / Life Yoga.

Controlling your personal information

You may choose to restrict the collection or use of your personal information in the following ways:

  • Whenever you are asked to fill in a form on the website, look for the box that you can click or statement where you can indicate that you do not want the information to be used by anybody for direct marketing purposes
  • If you have previously agreed to us using your personal information for direct marketing purposes, you may change your mind at any time by writing to or emailing us at

We will not sell, distribute or lease your personal information to third parties unless we are required by law to do so. We may use your personal information to send you promotional information about third parties which we think you may find interesting if you tell us that you wish this to happen.

You may request details of personal information which we hold about you under the Data Protection Act 1998.  If you would like a copy of the information held on you please write to Life Yoga, 279 Ringinglow Road, Sheffield, S11 7PZ.

If you believe that any information we are holding on you is incorrect or incomplete, please write to or email us as soon as possible, at the above address. We will promptly correct any information found to be incorrect.


From time to time Zoe Marciniak (Life Yoga) may take a photo of you in class to use in promotional material (Facebook, website, Twitter, Instagram, advertisements).  These photos usually do not show faces and you agree to their use.

Before commencing yoga with Zoe Marciniak (Life Yoga) in any online, private group or one to one classes, please sign to say that you understand the conditions lesson attendance.  Opt in also to receive class and workshop updates.
Re your email addresses, I have set up a temporary section in my Outlook for these lessons and when the madness is over, please let me know if you want removing from the list – in fact, you can do that at any time by dropping me an email. In general, I store all contacts in Outlook, backed up in Google (protected via passwords and Authenticator). I work for myself so it is just me that sees your info and if you ever want to leave my list, just say. I only ever ask for medical info in person or in Chat function if online and do not like to keep medical info in written form.