Mindful Movement & Energy — Registration Form

Registration Form

The information obtained during this evaluation will be treated as confidential and will not be released or revealed to anyone without your consent.
I would like to register for the:*

Half Day Escape being held on __/__/____3 Day 3 Night Women's Retreat being held on __/__/____2 Day 2 Night Women's Coastal Retreat being held on __/__/__5 Night 6 day Women’s France Retreat being held on__/__/__
If you have chosen a Women's France Retreat, please select your room arrangement

Single Room (subject to availability)Twin Share
Name of your preferred room companion/s
Preferred Date of Escape or Retreat*

DayMonthYear
Date
Name*

First NameSurname
Address*

Street Address

Street Address Line 2

SuburbState

Postcode
Mobile*
Occupation*
Gender*
Email Address

Confirmation Emailexample@example.com
Emergency Contact Name*
Contact Number*
Medical Information
Do you have medical clearance from a doctor to participate in physical activity?*

YesNo
Have you ever had or do you have the following?*

High Blood PressureHigh CholesterolStroke/Heart ConditionNerve PainChest PainStomach UlcerDiabetesEpilepsyBack or Joint PainArthritisCancerOther
If Yes, please provide details
Are you pregnant, planning to become pregnant or have you given birth in the last 8 weeks?*

YesNo
If Yes, please provide details
Do you have a family history of heart, stroke or raised cholesterol of relatives under the age of 65?*

YesNo
If Yes, please provide details
Have you ever had major surgery that would inhibit you from exercising?*

YesNo
If Yes, please provide details
When was the last time you had a medical check? *
Name of your regular Doctor*
Contact number *
Are you currently taking any medication?*

YesNo
If Yes, please provide details
Do you have health, fitness and wellness goals?*

YesNo
If Yes, please provide details
Do you currently have a health, fitness and wellness regime?*

YesNo
If Yes, please provide details
Signature
For all France Retreat and 3 day and 3 night Retreat registrations; once we receive your registration form, you will be notified by email to confirm your booking and the payment details. In the event your accommodation preference is not available, we will call you to discuss your options.

I certify that all of the information that I have provided on this application is true, accurate and complete.

In case of a medical emergency, I authorise the staff of Mindful Movement & Energy to contact the nearest doctor/ambulance and organise any medical attention on my behalf.

I accept responsibility for any costs incurred and release all Mindful Movement & Energy employees and contractors from any liability for injury incurred during my participation in any activities, events and retreats held by Mindful Movement and Energy on or off site of 3 Benjamin Close, Samford, Qld 4520.
Sign*

Clear
Date*

DayMonthYear
Date
Should be Empty:

Registration Form

Medical Information

Signature