Shanmukhi Mudra Registration Form
Isha Hatha Yoga - Shanmukhi Mudra

Saturday, January 25th 2020 - 12:30PM – 01:30PM

2065 Dundas St. E, Unit 103
Mississauga, L4X 2W1

Age: 14+

Program Fee: $80
Early Bird Fee: $60 (until 20 Jan 2020)
Treedollar discount: $10 (inquire within for details)

Summit Lalwani
Email address *
First Name *
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Last Name *
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Name you prefer to be called
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Phone Number *
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Educational Qualifications
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Residential Address:
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Zip/Postal Code
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Emergency Contact Name, Relationship and Phone Number
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How did you come to know of this program?
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Please provide details of yoga or meditation you have practices and how long you have been practicing.
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Have you learnt any other Isha Yoga practices? Yes/No. If Yes, please give details
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Please indicate below if you currently or previously have had any physical or mental ailments:
Any physical limitations or disabilities
Neck/Back aches/ injuries
Joint-related issues
Ligament Injuries
Spinal Conditions
Bowel/Bladder issues
Communicable disease
Chronic Pain
Glaucoma / retinal detachment / eye surgery
Depression / Psychosis
Respiratory Conditions
Heart Conditions
High Blood Pressure
Low Blood Pressure
Seizures / Epilepsy
Bleeding Disorders
Hospitalization for a psychiatric condition in the past
Please indicate below if you currently or previously have had any other physical or mental ailments not mentioned above. Please give details of the nature and duration of the condition and if you are currently undergoing any treatment.
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For women, Are you currently pregnant?
Name of your Cauvery Calling campaign
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# of Trees raised currently
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Comments and/or questions
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I hereby willingly undertake to attend this program completely. I take full responsibility for the result and indemnify the organizers against all claims and suits. I will not communicate the contents of the program, either directly or indirectly to anyone else. I understand the participation guidelines and agree to follow them. I hereby declare that the above information is true, accurate and complete to the best of my knowledge. (Electronic signature of your Full Name & Date is required in space below) *
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A copy of your responses will be emailed to the address you provided.
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