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Booking form for a retreat – first submission

Name*
First Last
Date of birth*
DD slash MM slash YYYY
Email*
Mobile number*
Name of retreat / event / class / workshop attending*
Date of event/retreat*
DD slash MM slash YYYY
How did you hear about the retreat?
How long have you been practicing yoga?*
- Just starting
- 1 - 3 years
- 3 - 5 years
- 5 - 10 years
- 10 years plus
Would you say your practice is -*
- Beginner
- Intermediate
- Advanced
Please describe your practice.
What are your aims from this course?
Do you have a meditation practice?
- Yes
- No
Do you want to meditate, or learn more about meditation?
- Yes
- No
Do you have any allergies (including food, feather, animals, essential oils ect)?*
- Yes
- No
Please detail your allergies below
Do you have any dietary requirements?*
- Yes
- No
Please detail your dietary requirements below
PAR-Q
If you answer ‘yes’ to any of the next 10 questions please talk to your doctor BEFORE the class / event / retreat / wellness to check that dynamic yoga or physical activity is suitable for you Discuss with your doctor which kinds of activities you wish to participate in and please do discuss with us.
Are you pregnant or recently had a baby?
- Yes
Further details - Are you pregnant or recently had a baby?
Do you have any neck or back injuries, current or historic?
- Yes
Further details - Do you have any neck or back injuries, current or historic?
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
- Yes
Further details - Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
In the past month, have you had chest pain while you were not doing physical activity?
- Yes
Further details - In the past month, have you had chest pain while you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
- Yes
Further details - Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by physical activity?
- Yes
Further details - Do you have a bone or joint problem that could be made worse by physical activity?
Do you feel pain in your chest when you do physical activity?
- Yes
Further details - Do you feel pain in your chest when you do physical activity?
Is your doctor currently prescribing drugs for your blood pressure or heart condition?
- Yes
Further details - Is your doctor currently prescribing drugs for your blood pressure or heart condition?
Have you had any recent injuries or operations?
- Yes
Further details - Have you had any recent injuries or operations?
Do you know of any other reason why you should not do physical activity?
- Yes
Further details - Do you know of any other reason why you should not do physical activity?
In Case of Emergency
ICE (In Case of Emergency) Name*
First Last
ICE (In Case of Emergency) Mobile*
To submit this form you need to agree to the event terms and conditions.
Click here to view the T&C's
Do you agree to our event T&C's?*
- I agree to the event terms and conditions

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