Consent received
Thank you. Your consent form has been recorded.
Already submitted
This email address has already submitted a consent form. If you believe this is a mistake, please contact info@yoga-cu.com.
Something went wrong
We couldn't load this form. Please refresh, or contact info@yoga-cu.com.
Iyengar Yoga Champaign-Urbana
Consent to Release
Information
Please fill out this form, indicating your preference for allowing us to store your case study in our archive. With approval from Lois, we will allow certified Iyengar teachers to view your case study for educational purposes. Your information will not be available to the public.
Consent to release
I consent to release my information as written in the case study by my teachers. I understand this includes medical information gathered in the pre-therapy intake survey, photos of me taken during the intensive, and notes and observations made by my teachers during the 2026 Therapy Intensive.
I understand that my case study will only be viewed by certified Iyengar teachers for educational purposes, and only with permission from Lois Steinberg.
I consent to release this information in perpetuity.
Identity protection
If you answered yes to the above question, please indicate whether you'd prefer to have censorship of your identifying information. You may select more than one box if applicable.
Comments/Questions/Concerns
You may also email us at yogacu@gmail.com.
Signature
By signing below, you confirm the preferences above accurately reflect your wishes.
This electronic signature is legally binding under the E-SIGN Act. Completing this form constitutes your agreement to the preferences indicated above.