Sound Bath Participant Form

Sound Bath Participant Form

Share your details, emergency contacts, and health/safety information for your Aqua Sound Bath session at Rossall School.
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Participation & Safety Screening
Can you comfortably swim or float in a swimming pool?
Can you safely get on and off an airbed without assistance?
Have you attended an Aqua Soundbath before?
Medical Conditions
Current or previous medical conditions
If you selected any of the above, please provide details.
Medical condition not listed
Recent Symptoms & Medication
Have you experienced any of the following within the last 48 hours?
Are you currently taking any medication that could affect balance, awareness, or concentration?
If yes, please provide details
Participant Declarations
I confirm the information provided is accurate
I understand this session is a wellness experience and is not intended to diagnose, treat or cure any medical condition
I understand participation is entirely voluntary
I agree to follow all instructions given by Rossall staff and the Yoga at the Farm instructor
I will immediately inform staff if I feel unwell or uncomfortable
I understand there are inherent risks associated with participating in a water-based activity
Session dates
Signature
Date

MonthDayYear
Date

Payment

Soundbath ticket

£25.00

Total

Debit or Credit Card
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty:

Sound Bath Participant Form

Participation & Safety Screening

Medical Conditions

Recent Symptoms & Medication

Participant Declarations

Payment*

Payment