Taiji /Qigong Registration Form

All items with (*) are compulsory

Applicant's Details

First Name (*)
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Last Name (*)
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Address (*)
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Postal Code (*)
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Phone (home)
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Phone (work)
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Mobile
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Email (*)
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Occupation (*)
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Date of Birth dd/mm/yyyy (*)
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Health Declaration

Are you aware of any physical impairments, injuries, medical conditions or health problems that currently affect you and that, in the interests of your safety, the school should be advised of?
YES / NO (*)
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If yes, please describe
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Have you suffered any incapacity requiring medical attention in the past 12 months?
YES / NO (*)
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If yes, please give details
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Are you taking any prescribed drugs which may impair reaction time or judgement?
YES / NO (*)
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If yes, which drugs?
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Declaration of Understanding

Taiji and Qigong are not a replacement for medical advice, diagnosis or treatment of pathological conditions. If you have an acute or chronic illness or disease, please seek medical attention from a qualified doctor.


Some Taiji and Qigong exercises may not be suitable for everyone. If you are unsure about Taiji or Qigong, or if you have any injuries or medical conditions that you think may affect your ability to participate, please consult your medical practitioner first.


Many Taiji and Qigong exercises are not suitable for pregnant women. However, Taiji and Qigong are excellent for post-natal women.


I have read and understood the contents of the Taiji / Qigong Registration Form or, if I did not understand it or any part of it, I requested an independent person to explain it to me.


I agree to the above
Declaration of Understanding

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Traditions That Have Healed and Inspired
for Thousands of Years


Shirsha Marie
Founder & Principal
Heart Mind Centre (est. 1986)
Post: P.O. Box 819 Byron Bay N.S.W. 2481 Australia
Tel: 0400 558181

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