Cart 0

Yoga Retreat Questionnaire

Name

First Name

Last Name

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Gender

Male

Female

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Relationship to Emergency contact

Main Questions

What type of accommodations are your interested in?

Single, Double, Triple , Family room 4-5 etc.

Describe your yoga practice

What does it mean to you? How often to do practice? How long have you been practicing?

Fitness level

Activities you participate in

Tell us about your health

recent surgeries, illnesses, medications, chronic conditions

Are/could you be pregnant now or have had a baby in the past 12 months?

YES

Do you have any food allergies/intolerances/preferences

provide details

Tell us about you.

What are you hobbies and interests?

What are your expectations for this retreat?

Anything else you would like us to know about you? Any questions , comments or concerns?

Liability disclaimer & Notice

I consulted a physician prior to enrolling to practice yoga. Otherwise, I assume the physical risk of my own physical condition, past and current medical issues/injuries/illness or medication that may effect me onthis retreat. I understand that yoga is not a substitute for medical attention, examination, diagnosis, or treatment. I recognize that it is my responsibility to notify my teacher of any serious illness or injury before every yoga session. I will not perform any postures to the extent of strain or pain. If at any time during the class, I feel discomfort or strain, I will come out of the pose. I accept that neither the teachers, personnel, BE Moved Power Yoga, LLC, nor Dominican Tree House Village and its owners are liable for any injury , or damages to person or property, resulting from taking the class or in the future and I use the premises at my own risk.