Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Your address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

We offer a vegetarian diet while on retreat. Do you have a severe food allergy, any sensitivities or a medically diagnosed intolerance of any kind? *

Yes

No

Are you currently taking any medicines or receiving any medical treatment? *

Yes

No

Muscular / Skeletal *

Injuries

Arthritis

Rheumatism

Other

None of the above

Respiratory *

Sinus

Asthma

Bronchitis

I'm a smoker

Other

None of the above

Reproductive *

Pregnant

Breast feeding

Miscarriage

Trying to conceive

Menstruation: PMT / painful / Irregular

Menopausal

None of the above

Other

Circulatory *

High blood pressure

Low blood pressure

Anaemia

Varicose Veins

Heart conditions

None of the above

Other

Digestive *

Diabetic

Food intolerances

Alcohol

Drugs

None of the above

Other

Excretory *

IBS (Irritable Bowel Syndrome)

Constipation

Diarrhoea

Flatulence

None of the above

Other

Urination *

Bladder

Kidney infections

Cystitis

Thrush

None of the above

Other

Nervous system *

Epilepsy

Headaches / migraines

Problems with sleep

None of the above

Other

Waiver of Liability and Informed Consent Release for Yoga, Meditation and Sound Healing practices on retreats with Amanda Denton and Tamara Klien *

I am participating in a programme of instruction in classes and practices offered at this retreat. I have been advised and I understand that participation in Yoga and other embodiment practices like any physical conditioning or exercise programme presents some unavoidable risk of injury especially to people who have pre‐existing injuries, illness or medical disabilities. I recognise that changes may occur as a result of these physical as well as mental and spiritual practices are concerned. For example, feelings of tiredness, light‐headedness, increased energy, mood changes, etc. 

 I also understand that a medical evaluation is advisable before commencing any programme of physical conditioning or exercise. I have and will continue to keep my Yoga, Mindfulness & Sound Healing instructors on the retreat informed of any physical condition or disability which would prevent or limit my participation in an exercise programme. I acknowledge that although the programme may have substantial physical benefits my instructors on the retreat are not engaged in diagnosing or treating medical diseases or deficiencies. I expressly assume all risks of my participation in this Yoga, Meditation & Sound Healing programme and waive any claim which I might otherwise bring against my instructors on this retreat or against the operators of the retreat as a result of injuries from or relating to my participation in this programme. I confirm that all the information provided in this questionnaire is true to the best of my knowledge and I am not aware of any reason why I should not participate in this retreat or these classes. By signing below I agree to the above (acting as e-signature):

First Name

Last Name