YOGA FOR CANCER CARE PROGRAM

YOGA for CANCER CARE PROGRAM

Application form cum case record
Justice M. L. Pendse Centre for
Cancer Survivors and Lifestyle Conditions

A Holistic Approach to Healing and Transformation
(Two Week Program)

Step 1 - Please fill in the form with details

Step 2 - Your details shall be reviewed by our specialists and admission confirmed

Step 3 - Once confirmed the link for final booking and stay will be shared with you.

Step 4 - Arrival and experience

Step 5 - Conclude with greater positivity and health.
Select Date
Full Name*

First NameLast Name
Gender*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Mobile Number*
(Preferably a WhatsApp number)
Age*
Height
(in cm)
Occupation*
English Proficiency*

YesNo
Select Accommodation
Medical Information
Have THREE (3) months elapsed from your last treatment?*

YesNo
Thankyou for your interest in the program.

We request you to apply for the program once three months have elapsed from the recent treatment.
Are you able to attend the program on your own (without any dependancies)?*

YesNo
Our programs are designed for participants who are independent
Select Program Dates
Please share your diagnosed health condition.*
Please share about your treatments undergone:*
Additional therapies that have been undertaken for the given health condition?
Please share your reason to attend the program:*
Weight*
(KG)
Please upload your reports for review by the Doctors team*

Browse Files
File format allowed - pdf, doc, docx, zip, jpg, jpeg, png Cancelof
Do you suffer from diabetes, asthma, blood pressure or any other ailments?*

YesNo
If yes, please mention them
Would you like to avail 'Subsidy' for the program?*

YesNo
If yes, please mention the reason for opting for a subsidy
We may further require informations /documentation to consider you under subsidy.
Select Accommodation Type
Accommodation as per choice will be allotted on first cum first serve basis.

YOGA for CANCER CARE PROGRAM

Medical Information

Lifestyle Information