Registration Form for HeART-Full Retreat
November 9-11, 2018 with Paola Cardona & Michelle Chua
Email address *
Full Name: *
Your answer
Today's Date: *
MM
/
DD
/
YYYY
Phone Number(s): *
Your answer
How did you hear about this retreat? *
Your answer
Explain your intention for joining HeART-Full Women's Weekend Retreat, on November 9-11, 2018 in Ojai, CA. *
Your answer
Name an Emergency Contact, Their Relationship to You & Their Phone Number *
Your answer
Name a 2nd Emergency Contact, Their Relationship to You & Their Phone Number. *
Your answer
T-Shirt Size: *
Accommodation Choice: *
*If you chose Shared Queen Bed Accommodation in Private Room, Name the Guest you will be sharing with. Please submit 1 total payment for both guests.
Your answer
Explain Any Food Allergies, Dietary Restrictions & Food Preferences. *
Note: All meals provided are vegan.
Your answer
Describe any health, medical or sleeping conditions that may affect you or guests you will be sharing space with on this retreat. *
Example: I snore loudly when I sleep.
Your answer
Describe Your Physical Fitness Level & Experience with Yoga. *
Describe how long and frequently you've been practicing yoga & what style(s). Note: All ability levels are welcome.
Your answer
Indicate Amount of Registration Payment you are submitting with this form: *
Your answer
Type your name below if you understand that your registration payment is non-refundable and non-transferable. *
Your answer
Type your name below if you understand and agree with the following Liability Waiver: While Luna Mama, Root 2 Rise Yoga, Paola Cardona and Michelle Chua prioritize your safety above all, there are inherent risks involved in participating in physical activities, such as yoga, outdoor excursions and recreation. These risks are not limited to damage or loss of personal belongings and personal injury. By signing below, you, the retreat participant, state that you are in satisfactory health and suffer no physical impairment to voluntarily participate in the yoga sessions, outdoor excursions and recreation per retreat description. You accept and assume all risks existing in our retreat activities in Ojai. You agree to research the risks of those activities for which you are not aware. You agree to inform Michelle Chua and Paola Cardona on this registration form of any allergies, dietary needs or preconditions that may affect your and others’ safety and well being. You are responsible for bringing sufficient legal medications or health aids you may need. You and your associates (i.e., family, friends, etc.) voluntarily waive any claim to maintain a lawsuit or demands of any kind against Luna Mama, Root 2 Rise Yoga, Paola Cardona and Michelle Chua for any injury, illness, death, accident or loss or damage of personal property, which may occur during your participation on this yoga retreat in Ojai, CA. We recommend that all participants purchase travel insurance that covers emergency medical care, cancellation of flights and for loss or theft of personal items, if applicable. *
Your answer
Thank you for choosing to join us and investing in your wellness!
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service