Retreat Registration

(Please fill in & submit the following form to complete the registration process)
Retreat Information
Mid-Summer Vitalize Yoga Retreat July 23-26, 2015
Ireland Adventure Yoga Retreat – Sep 12-19, 2015

Your Information
Last Name: First Name: Male Female
Address: Age:
City:
State/Prov:
Postal/Zip:
Country:
Phone Home: Phone Work: Phone Cell:
email:

Emergency Contact Information
Last Name: First Name: Relationship:
Address:
City:
State/Prov:
Postal/Zip:
Country:
Phone Day: Phone Night: Phone Cell:
email:

Activity Skills

Yoga:
Beginner Intermediate Advanced


Medical Information

Height and Weight:
Height: Weight:

Physical & Emotional Health Assessment:
Beginner Intermediate Advanced

Fitness Assessment:
Beginner Intermediate Advanced

Physical or medical limitations that might affect your participation on this retreat:

Do you have allergies that might affect you on this retreat: Yes No

If Yes, please indicate it in the space below:

Do you have any dietary restrictions? Yes No

If Yes, please indicate it in the space below:

Please list any medication taken and for what condition:

Are you pregnant? Yes No

If Yes, please indicate the expected due date in the space below:

Do you have any sleeping disorders or phobias? Yes No

If Yes, please provide details in the space below:

List any major illnesses and the dates:

Family Doctor's Name: 

Phone: 

How did you hear about this event?