Silent Retreat Questionnaire
Name
Your answer
Phone Number
Your answer
e-mail
Your answer
What is your experience / practice of meditation:
Your answer
Would you like to be added to our Newsletter to receive info on class updates, workshops and retreats?
Please share any food allergies or sensitivities:
Your answer
Do you have any of the following medical or health conditions:
Any illness or other health concerns:
Your answer
*WAIVER/RELEASE LIABILITY
I recognize that it is my responsibility to consult with my doctor, if I have a medical condition, prior to starting a yoga program. I realize that it is my responsibility to notify my instructor of any serious illness or injury before every class. I understand that these classes involve physical activity and even with the best of intentions it is possible that injuries may result or prior conditions may be aggravated. If at any time during the class, I experience discomfort or strain, I will listen to my body and rest. I freely accept and assume full responsibility for any and all injury, harm or loss whatsoever arising or resulting from my participation in these classes. I hereby release Nienke Young from any and all liability for any injury, harm, damage, loss or consequential loss or damage that I may undergo arising or resulting from participation in these classes. I agree to waive any and all claims of any nature or kind whatsoever that I or my heirs, executors, estate trustees, administrators, assigns or representatives have or may have in the future against the Nienke Young.
PLEASE READ THE STATEMENT ABOVE AND TYPE YOUR NAME TO APPROVE
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