Name *
If you do not have a cellphone please put another contact number here. This will be used to contact you for any last minute changes in classes and other Nia 'emergencies'!
Birth Date
Birth Date
Day and month please, year if you like!
The information you disclose on this form will remain private and will not be shared with anybody except in a health/medical emergency that may result from your participation in a Nia class. Its intended purpose is to provide valuable information to your Nia teacher so that they may give the best care to you in an emergency.
eg. Jane Blogs - Mother
Cellphone is preferred.
Have you participated in a Nia class before this?
Have you participated any of the following activities?
You may choose more than one
Do you exercise for at least 30mins per day?
Nia classes are suitable for ALL ages, fitness levels, body shapes and movement ability. Nia is suitable for YOU as long as you are wiling to LISTEN to Your Body's Way and TWEAK the moves so that you may feel PLEASURE. Are you willing to do this?
Do you smoke? And if so, how many per day?
Do you have advice from a physician not to exercise? *
Are you currently pregnant?
Marketing & Communications
How did you first hear about Nia in Waikato?
Please give me more detail. From who did you hear about Nia? Where was the poster/flyer location? Which radio did you hear about Nia on? Which newspaper? Other?
I would like to sign up to the Nia in Waikato e-newsletter and be kept informed of local Nia classes and events and workshops held in NZ *
This is a monthly e-newsletter which you can opt out of at anytime! Highly recommended if you want to be kept in the loop!
I would like to recieve Nia with Nik's Contemplations newsletter *
This newsletter is about Nik's thoughts on bringing your practice in the classroom out in to your life.
If a Nia class has to be cancelled due to unforeseen circumstances, notification will be posted on Nia in Waikato's Facebook page and via mass email for cancellations within 24 hours. For shorter time frames of cancellation of classes, Nicola and/or Alex will inform regular students via group text, email and facebook post. Would you like to receive texts in this case? *
Waiver Release
To the best of my knowledge the information I have provided on this form is accurate. My participation in Nia classes is voluntary and I declare myself and myself only to be responsible for my own health and safety while participating in Nia classes. I release my Nia teacher, from any responsibility for any consequences that may arise from my participation in Nia classes. *
By choosing 'Yes, I agree' below, you acknowledge that you understand the above and are in agreement and will act as your signature to the waiver.
Date *
A special request from me!
Please note that by filling out this field, you give consent to Nia in Waikato to use your testimonial (and name and age) in future marketing and promotional material. If you do not give consent, but just want to comment and give us some love, please say so by starting your statement with "for your eyes only!"