Day Retreat at the Ciderie Registration Form

GUEST INFORMATION

Name

First NameLast Name

Email (Please double check spelling)

example@example.com

Birthdate

Date

Home Number

Area CodePhone Number

Cell Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

EMERGENCY INFORMATION

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Have you practiced Yoga before?

If YES, what type of yoga have you practiced?

Do you have any health limitations or physical injuries? Please indicate if you have any major health issues (ex high/low blood pressure, arthritis, asthma, diabetes, seizures, osteoporosis, etc.)

Gender

MaleFemaleOther

Women: Are you pregnant or is there any possibility of being pregnant? If YES, please indicate your due date

Do you have any special dietary requirements? (eg: gluten-free (please specify if you are celiac), allergies, vegan etc…)

How did you learn about the Cider Retreat?

What inspired you to come to this retreat?

AGREEMENT OF RELEASE AND WAIVER OF LIABILITY I hereby agree to the following: As I participate in activities offered by the hosts and special guests, I understand that the offerings of this retreat are not a substitute for medical attention, examination, diagnosis, or treatment. I will receive fitness related information and instruction. I recognize that all exercise programs require physical exertion that may be strenuous and may cause physical injury and I am fully aware of the risks and hazards. If at any time during the activities I feel discomfort or pain, I will inform and seek assistance from the teacher. I may rest at any time during the class. I will listen to my body and respect its limits. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any activity program. I represent and warrant that I am physically and mentally fit and I have no medical condition that would prevent my participation in fitness classes or workshops. I recognize that it is my responsibility to notify my teacher of any serious illness or injury before the retreat. I accept that neither the instructor, nor the hosting facility, are liable for any injury, or damages, to person or property, resulting from my participation in this retreat. I understand that my payment is due in full by September 4, 2022. Cancellation fees will apply due to associated costs. I agree that all cancellations made less than 7 days in advance of the retreat be paid in full and that I may transfer my spot to another person. Exclusion of Participation: In the unfortunate circumstance, if a guest conceals physical and/or health issues, is unfit, and/or causes disruptions that endanger the provision of the service and/or the health of other participants,facilitators, or equipment the guest can be excluded from the participation of the Retreat after an initial warning. If the situation arises, the contract will be terminated without further notice, already paid costs are non-refundable and incurring costs are to be paid by the guest. I have read the above release and waiver of liability and fully understand it’s contents as well as the Refund/Cancellation Policies. I voluntarily agree to the terms and conditions stated above.

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.