Name *

First Name

Last Name

Phone Number *

Country

(###)

###

####

Date of birth *

MM

DD

YYYY

Personal health *

Do you have or have you suffered from any injuries or medical issues, or are taking medication that is likely to affect your performance on the retreat? (e.g. but not limited to: heart conditions or medication/ pre or post natal/ diabetes or epilepsy/ asthma or breathing difficulties/ allergies/ visual or hearing impairment/ spells of dizziness/ high blood pressure) OR has your doctor advised you against physical exercise of any type?

YES

NO

Where did you hear about the retreats? *

Google search

Instagram

Word of mouth

Previous client

Online retreat agent

Other

Informed consent & liability waiver *

By ticking the below YES box you confirm you have read and understood the terms and conditions (found in the link below this form) in relation to your retreat booking, or private training. Liability waiver to be found under point 7. PERSONAL HEALTH, MEDICAL AND INJURIES.

YES

NO