Darjeeling Retreat

First Name *

Last Name *

Gender *

Date of birth

Phone *

Email *

Address

Street Address *

City *

State *

Country *

Country

Postal code *

Emergency Contact Name *

Emergency Contact Number *

Do you have any of the following conditions that your instructor should be aware of:

Asthma

Pregnancy

Epilepsy/Seizures

Heart/Circulatory Problems

High or Low Blood Pressure

Dizzy spells/Fainting

Diabetes

Cervical Pain

Irregular menstrual cycle

Migraine

None

Other

If your answer above is others, please specify

Did you have Neck/Back/Spine injury: *

Did you have Joint injury (ankle, knee, hip, elbow shoulder)? *

Did you have muscular injury? *

Other medical condition, injury, or disability: *

Any recent surgery: *

Please specify if you have any diet restrictions

Do you occasionally feel stressed, anxious, or depressed? Rank it from 1 to 10. *

Yoga Level: *

I hereby give my consent for Rudrakshaa Yogashala to take photos/videos for promotional purposes. *

Yes

I give permission the teacher to provide physical adjustments and touch to correct my posture during the class. *

Yes

Waiver and Release: By signing this form, I acknowledge that I am voluntarily participating in yoga classes and understand the associated risks. I kindly release the instructor and the organization from any responsibility or liability for any injury or harm that may arise during my participation.

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Retreat Payment *

S$ 1650

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