Registration Form
Please fill in the information below in order to complete registration.
This information will allow us to ensure that you can make the most of our Programs. All personal information will remain strictly confidential.
Email address *
Program Attending *
Personal information
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
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DD
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YYYY
Gender *
Address *
Your answer
City *
Your answer
Country *
Your answer
Postal Code *
Your answer
Phone *
Your answer
Emergency Contact Information
Name *
Your answer
Relationship *
Your answer
Phone number *
Your answer
Experience of Yoga
Please give details of the types of Yoga you have practiced, how long you have been practicing and how often do you practice.
Your answer
Health Information
Height *
Your answer
Weight *
Your answer
Please indicate if you currently suffer from, or have previously suffered from any of the following conditions:
Colonne 1
Physical limitations or disabilities
Communicable disease
Diabetes/Hypoglycemia
Heart conditions
High/Low blood pressure
Stroke
Asthma/ Respiratory conditions
Heartburn, peptic ulcer or intestinal conditions
Chronic pain
Arthritis
Osteoporosis
Seizures/Epilepsy
Spinal conditions
Anemia
Endocrine conditions
Urinary conditions
Glaucoma
Hernia (abdominal)
Surgery in the last 6 months
Injury in the last 3 years
Psychotherapy psychological therapy or counseling in the last 5 years
Treatment programme for alcohol/substance
None
Other
If you have checked any of the above, please give details of the nature and duration of the condition. Please specify if you are currently on any medications. For what condition(s)? If yes, please describe any known side effects of these medications (e.g. change of heart rate, lack of coordination, etc.) that may impact your yoga practice:
Your answer
Women Only
Are you currently pregnant?
Allergy History
Please indicate if you currently experience any allergies *
If your answer is yes, please give details of the nature of the allergy and the treatment required in case of emergency
Your answer
How did you hear about us?
*
Your answer
Agreement

It is always important to consult your doctor before beginning a new exercise program. Make sure you always follow the teacher's instructions. As a student, you remain fully responsible for your practice, safety and well-being. The responsibility to take a posture or not, to keep it or to leave it, comes back to you. By signing this form, I release the teachers and leaders of Samsara Hatha Yoga from all liability and waive all rights to bring an action, claim and cause of action arising from my participation in this course.
I hereby agree with the above statements and I declare that the above information is true, accurate and complete to the best of my knowledge. *
Date *
MM
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YYYY
During our programs, we sometimes take photos for our portfolio / promotion /web content. If you do not wish to be photographed, or give permission for these intent, please let us know. *
Payment
Exact amount via Interac to patrick@samsarahathayoga.com
or via Paypal at https://www.paypal.me/PatrickDesrochers

Refund Policy for Cancellations

•Full refund 8 days prior to program date.
•50% refund 7 days prior to program date.
•No refunds 2 days prior to program date.

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