Spring Cleanse - Registration Form
Name: *
Please enter your first and last name.
Your answer
Date of Birth: *
Please enter your date of birth.
Profession: *
Please enter your current profession (yoga teacher, doctor, student, retired, unemployed, etc).
Your answer
Email: *
Please enter a valid email address we can use to contact you.
Your answer
Confirm Email: *
Please re-enter the previous email address to confirm it is correct.
Your answer
Phone Number: *
Please enter your primary phone number.
Your answer
Alternate Phone Numbers:
Optional: Enter any alternate phone numbers we may use to contact you.
Your answer
Fax Number:
Optional: Enter a fax number we can use to contact you.
Your answer
Address: *
Please enter your mailing address, with street number, name, city, province/state, country, and postal/zip code.
Your answer
Previous Yoga Experience: *
What previous experience do you have with any kind of yoga? If none, write N/A.
Your answer
Interest in Course: *
Why you are interested in taking this course?
Your answer
Heard About Course: *
How did you hear about this course?
Your answer
Any Health Limitations?:
Do you have any physical/psychological ailments that affect your ability to practice Kundalini Yoga?
Your answer
Any Medication?
Are you taking any medication that may impact your ability to practice Kundalini Yoga? E.g. high blood pressure medication
Your answer
Program Waiver
I understand that it is my responsibility to consult with a physician and/or counselor/psychiatrist prior to and regarding my participation in the Spring Cleanse Program. I represent and warrant that I am physically fit and I have no medical condition that would prevent my participating to the best of my ability in the Program. I understand that I must consistently monitor my energy and comfort, and take full responsibility for my own pacing of what I can and cannot do at this time. I understand that the program activities and homework are voluntary and that Kundalini Yoga is a non-forced, non-aggressive, non-competitive activity. I assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the Spring Cleanse Program. I understand that I have choice in what I share about myself.

I will not hold Sat Dharam Kaur ND or other instructors responsible for any injuries or actions arising out of or in any way connected with my participation in this program. I acknowledge that a risk of personal injury may be involved in any exercise or yoga program, and understand that it is my responsibility to refrain from performing any yoga postures or exercises that cause me pain or discomfort, physically or emotionally. I acknowledge that in a professional manner, physical contact may be required for Kundalini Yoga instruction.

I, my heirs or legal representatives forever release, waive, discharge and covenant not to sue or make any claims of any kind whatsoever against the Spring Cleanse Program or any of the aforementioned parties for any injury, property damage/loss, or death caused by their negligence or other acts.

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