Notting Hill 9th September 2023

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Mindfulness Retreat Booking Form and health questionnaire

1. Please submit your Voucher number and the Pin number if the voucher has one. *

2. Enter Your Full Name *

6. Provide your email address *

5. Enter your mobile Telephone number *

3. Enter your age and profession

3. Please provide us with an emergency contact and telephone number. *

4. Please tell us about your experience *

I am new to mindfulness

I know a bit about mindfulness

I have a daily mindfulness practice in place

5. Have you practiced yoga before?

Yes

Clear selection

6. Will you be bringing you own yoga mat? *

Yes

7. What would you like to get out of the retreat? *

8. Medical - Are you currently taking any prescribed medication that we need to know about? Please let us know if you are suffering or if you have in the last 5 years suffered from any of the following; You are pregnant Back, neck, Hip or knees pain Other pain or injury to any joints Headache / migraine High blood pressure Circulatory disturbance e.g Varicose veins, leg swelling, cold extremities, etc. Heart complaints: irregular beat, chest pain, etc. Breathing difficulties: breathlessness, cough, wheezing, pain on breathing, etc. Reduced bone density? e.g. Osteoporosis, osteopenia Disturbance or changes in eyesight, hearing; dizziness and balance problems Numbness or tingling in the arms, legs or face Muscular weakness; disturbance of balance or coordination; tremor Anxiety; depression; diagnosed psychiatric/psychological Cancer Diabetes Multiple Sclerosis Epilepsy M.E Significant Accident or injury Surgery Wear a hearing aid *

9. DIETARY REQUIREMENTS Do you have dietary restrictions, or life threatening allergies? (Nuts, gluten or lactose intolerant, diabetic, hypoglycaemic, etc.)or are you a vegan?

Please let us know if there is anything in particular you will not eat.

* 10. Disclaimer, I am aware of my own health and physical condition and having knowledge that my participation in the retreat day may be injurious to my health, I am voluntarily participating in the retreat with Synergy Experiences. Having such knowledge, I hereby release Synergy Experiences from liability for accidental injury or illness, which I may incur as a result of participating in the said retreat. I hereby assume all risks connected therewith and consent to participate in the said retreat day. I agree to disclose any physical limitations, disabilities, ailments or impairments, which may affect my ability to participate in the said retreat. By attending the retreat day I agree with this disclaimer that Synergy Experiences are not liable for guests injuries, illnesses, medical or psychiatric conditions developed during or subsequent to the retreat, loss or damage to personal property of guests. With regards to all forms of exercise if you have any doubt about your level of health and fitness it is advisable to consult your GP prior to the commencement of any new fitness plan. The instructor must be informed of any injuries, handicaps or medical problems prior to joining the Retreat.I acknowledge that I exercise and go on the walk entirely and completely at my own risk and I do not hold Synergy Experiences or any of their partner companies responsible for any injury that occur to me prior, during or after the retreat. *

Yes, I have read and understood the Disclaimer and agree.

No, and I will not be attending.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Synergy Jewellery. Report Abuse

Forms