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Registration

REGISTRATION

Weekend Yoga Retreat with Hollace Stephenson

Registration Form

First Name: Last Name:

Street Address:

City: State: Zipcode:

Country:

Primary E-mail:

Day Time Phone:

Evening Phone:

Occupation:

Gender: Female Male

Marital Status:

Date of Birth:

Emergency Contact:

Emergency Contact Phone:

How did you hear about the Weekend Yoga Retreat?

How long have you been practicing Yoga?

Have you attended any yoga classes/workshops led by Hollace in the past?
If so, please list where & when:

What is your primary intention for attending this workshop?

What is one thing you would like to walk away with after attending this workshop?

Are you able to attend this workshop with a full commitment to yourself from start time to end time
(2pm Friday until 2pm Sunday)?

Are you a yoga instructor? If so, for how long and under whom do you study/have you studied?

Please describe the state of your current physical health?

Are you currently under the care of a physician or other health care professional either traditional or alternative? If so please inform the staff of any special needs you may have.

Please place a check if you currently have any of the following medical conditions

Diabetes if yes, do you control with medication?

Epilepsy if yes, do you control with medication?

Heart Condition if yes, do you control with medication?

High Blood Pressure if yes, do you control with medication?

Pregnancy if yes, what trimester:

Recent Surgery if yes, please describe:

Cancer if yes, please describe:

If yes to any of the above, please provide the staff with a list of your most current health care providers in case of an emergency.

Do you have or have you ever had any eating disorders?
Yes No Sometimes

Do you drink alcohol? If so, how much & how often?

Do you smoke? If so, how much & how often?

Do you use recreational drugs? If so, how much & how often?