Questionnaire & Liability Release
Thank you for registering for a Kula Collective offering. Please fill out the form below so that we may be better prepared to co-create the best possible experience with you. The more you share, the better we will be able to support you in this process. Thanks
Personal Information
Full Name
*
First Name
Last Name
Date of Birth
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Year
Phone Number
E-mail Address
*
example@example.com
Passport Number:
*
What are your preferred pronouns?
*
Are you open to co-ed housing?
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Yes
No
Do you give Kula consent to be filmed/photographed during your course? Please note that video/photo may be used in Kula educational/promotional material.
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Yes
No
If Kula Collective posts photos or videos from your training/retreat to Instagram, would you like to be tagged?
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Yes
No
If yes, please provide your Instagram handle:
Do you have dietary restrictions?
Vegan
Gluten Free
Vegan + Gluten Free
Vegetarian
Allergies
If allergies or other, please explain.
If you checked any of the above, please provide any pertinent information.
Are you pregnant?
*
Yes
No
Do you have any injuries? Please explain.
Are you currently receiving therapy or attending any kind of support group?
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Yes
No
If yes, please describe.
Are you currently taking any medications?
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Yes
No
If yes, please explain why you are taking this medication and how frequently you use it.
Do you have any medical history we should know about? if yes, please explain.
Do you feel mentally and emotionally stable to participate in a 25-30 day intensive training?
*
Yes
No
Is there anything else we should know about your health?
I understand that this program is designed to deepen my yoga practice and it is in no way a detox program or therapeutic mental health retreat. I agree that I am mentally, physically, and emotionally fit to participate in this yoga teacher training course.
*
Yes
Emergency Contact Details
Name of Emergency Contact
*
First Name
Last Name
Emergency Contact Phone number (include area code)
Emergency Contact Email
*
example@example.com
Declaration of Honesty
I declare that I have read and understood the information in this medical form. I further declare that I have answered all the above questions fully and honestly and have not withheld any information that I believe could be important.
By checking this box, you declare you have answered all the above questions fully & honestly and have not withheld any information that you believe is important.
*
Yes, I Agree
Liability Waiver and Release
I understand that my participation in this retreat/training is entirely voluntary, under my own free will and at my own risk. I fully understand the arduous nature of this retreat.I understand that I may be living in a rustic location that is not easily accessible. I agree to release and hold Kula Collective and all other facilitators, organizers, and property owners completely harmless of any and all liability if I sustain any injuries, or medical conditions arising from my participation in any and all activities associated with this retreat/training.In order to maintain the integrity and safety for me and my peers, Kula has the right to ask me to leave the course. I will be required to leave this course if I pose a threat to me and others in the course. I understand an inherent risk of exposure to COVID-19 exists in any shared place where people are present including this event. By attending the event, I assume all risks, whether occurring prior to, during or after and recognize that attendance is voluntary and may result in personal injury, including possible death and exposure to COVID-19 and agree to release, waive and discharge event management, its sponsors and all of their respective agents, officers, directors, owners, employees and volunteers from all claims resulting directly or indirectly from my attendance.In signing this disclaimer I agree to accept full responsibility for my own safety, mental health and well being and agree to following the advice of the facilitators for my well being and will adhere to all program guidelines.By writing my name below, I indicate that I have read and understand everything contained in this Liability Waiver and Release Form, that I agree not to bring any lawsuit for damages regardless of whether or not negligence can be demonstrated and that I am releasing all parties associated with Kula Collective from any damages whatsoever.By signing this Liability Waiver and Release Form, I give permission for the use of any photographs/video to be used for educational, humanitarian, and marketing publication purposes.
By checking this box I affirm that I have read, understand and agree with the above LIABILITY WAIVER AND RELEASE form.
*
Yes, I agree
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