Retreat Registration Form

Guest Information

Name

First NameLast Name

Birthdate

Date

Email

example@example.com

Cell Number

Emergency Information

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact's Name

First NameLast Name

Phone Number

Alt. Phone Number

Have you practiced Yoga before?

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.)

If yes, what type of yoga have you practiced?

Gender

MaleFemale

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

Date

Are you bothered by scents (essential oils, incense, perfumes etc.)? If yes, please let us know the details.

What inspired you to come to this retreat?

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

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 facilitators.

I may rest at any time during the class and over the weekend. I will listen to my body and respect its limits on any given day.

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 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 instructors of any serious illness or injury before every class.

I accept that neither the instructors, nor the hosting facility or any of the organizing parties are liable for any injury, or damages, to person or property, resulting from my participation in this reatreat.

25% cancellation fees will apply due to associated costs such as the catering, accomodations, special guests, etc. up to a month in advance. Cancelleations up to 2 weeks in advance 50% fee will apply. I agree to above fees and I may transfer my spot to another person.

I am not registered to this retreat until full payment has been made early bird price of $950 ends on April 15th, after that full price of $1150 must be paid by May 10th, 2025. Option to send payment through Zelle account bewellyogaom@gmail.com

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.

Signature

Date Signed

Date