First Name

Last Name

Phone *

Email *

Participants_Age *

Address *

Street Address *

City *

State *

Country *

Postal Code

Preferred location for the workshop? *

Manhattan, NYC

Hillsborough, NJ

Teacher comes to my home

I can come to the teacher's location

In my city/home city

Other (Please specify your preferred location in the comments at the end of the form)

Emergency Contact Full Name *

Emergency Contact Relationship *

Emergency Contact Phone *

Please give details of yoga or meditation you have practiced and how long you have been practicing:

Have you learnt any other Isha Yoga practices? *

Yes

No

HEALTH INFORMATION

Any physical limitations or disabilities: *

Yes

No

Neck/Back aches/ injuries: *

Yes

No

Joint-related issues: *

Yes

No

Ligament injuries: *

Yes

No

Spinal conditions: *

Yes

No

Bowel/Bladder issues: *

Yes

No

Communicable disease: *

Yes

No

Chronic pain: *

Yes

No

Glaucoma / retinal detachment /eye surgery: *

Yes

No

Depression/ Psychosis: *

Yes

No

Diabetes : *

Yes

No

Respiratory conditions: *

Yes

No

Heart conditions: *

Yes

No

High blood pressure: *

Yes

No

Low blood pressure: *

Yes

No

Seizures/Epilepsy: *

Yes

No

Stroke: *

Yes

No

Bleeding disorders: *

Yes

No

Hernia *

Yes

No

Hospitalization for a psychiatric condition in the past: *

Yes

No

Any Serious illness in the last three years: *

Yes

No

Any Injury in the last three years: *

Yes

No

Surgery in the last three years: *

Yes

No

Psychotherapy, psychological therapy and counseling in the last five years: *

Yes

No

If any of the above is selected as Yes, please give details of the nature and duration of the condition and if you are currently undergoing any treatment or else write n/a *

H/O Smoking: *

Yes

No

H/O Drugs: *

Yes

No

H/O Alcohol: *

Yes

No

For women, Are you currently pregnant or planning for pregnancy ? *

Yes

No

Any other comments:

Next Steps *

To help us connect smoothly, please share three days and time windows that feel convenient for a short 15-minute Zoom conversation. This will help us listen, clarify, and thoughtfully plan your next steps.

I hereby willingly undertake to attend this program completely. I take full responsibility for the result

and indemnify the organizers against all claims and suits. I will not communicate the contents of the

program, either directly or indirectly to anyone else. I understand the participation guidelines and

agree to follow them. I hereby declare that the above information is true, accurate and complete to the

best of my knowledge.

Date

Signature

Clear

By checking this box, I consent to receive non-marketing text messages from Yoga Nebula about Isha Hatha Yoga Workshop. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others.from Yoga Nebula at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

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