Thank you for your interest in Wholehearter Yoga.

If you have not yet taken a look at the service you're interested in, please do so before taking the time to fill out this form.  Your responses are kept strictly confidential and I look forward to hearing from you!



Name *
Address *
Phone *
(For class cancellations and communication between sessions as needed)
Bithdate *
I am interested in: *
Please check all that apply
Be advised that evening time slots are in extremely high demand. Please list all possibilities.
Privately, in a studio or at home all count as 'yes!'
Please check all the words below that you would regularly use to describe yourself. *
Please describe any exercise routine, workload, recreation, schedule...etc.
Please indicate your typical feelings about the following statements: *
Please indicate your typical feelings about the following statements:
I regularly sleep well and wake feeling rested.
I handle stressful situations well (such as a car accident, illness or job loss)
I have multiple hobbies or self-care routines to wind down and manage my stress level.
I have adequate relationship support from family, friends...etc.
If necessary, I am willing to work hard to modify my habits, lifestyle and mind.
Please be as specific as possible. Thank you for your time!
• I understand and appreciate the physical risks involved in a yoga practice and voluntarily assume any and all risks • I am in proper physical condition to participate in this class or event • I agree to release and forever discharge Rosslyn Kemerer & Wholehearter Yoga from any and all liability for any injury • I understand that if I am unable to keep my scheduled private lesson appointment, I must offer the courtesy of 24 hours advanced notice via phone call or text • If I offer less than 24 hours advance notice, I may be charged up to half the price of the lesson • Same day cancellations will result in full payment