Daufuskie Island Retreat Waitlist
Registration Form
Guest Information
Name
*
First Name
Last Name
Birthdate
*
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Month
-
Day
Year
Date
Email
*
example@example.com
Cell Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Other
Emergency Information
Emergency Contact's Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Have you practiced Yoga before?
Please Select
Yes
No
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.)
Women: Are you pregnant or is there any possibility of being pregnant? If Yes, please indicate your due date
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Month
-
Day
Year
Date
Are you bothered by scents (essential oils, incense, perfumes etc.)? If yes, please let us know the details.
Do you have any special dietary requirements? (eg: gluten-free (please specify if you are celiac), allergies, vegan etc…)
What inspired you to come to this retreat, and how did you hear about it?
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit Form
Submit Form
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