Name
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First Name
Last Name
Email
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Which retreat are you joining?
Emergency Contact
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Please list any dietary restrictions
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Please list any food allergies
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How often do you practice yoga?
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Which styles of yoga do you prefer to practice?
How long have you been practicing yoga?
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Have you attended a retreat before?
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If yes, please specify
Please list any physical ailments you currently suffer from, or have suffered from in the past 5 years
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Are you currently taking any medications?
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If you answered "yes" above, please list the medications here
Do you have a history of strokes, heart disease, high blood pressure, hypertension, seizures, lung disease, arthritis, epilepsy?
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Do you have a history of mental illness?
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If yes, please explain
Do you have a history of spinal injuries, bone fractures/breaks?
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Have you had any recent surgeries/operations?
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If yes, please explain
Is there anything you would like us to know in order to ensure you have the most wonderful experience and create a nourishing environment?
Waiver of Liability & Informed Consent Release for Akna Collective Retreats
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I am participating in a program of instruction in Yoga classes offered at this retreat. I have been advised and I understand that participation in Yoga, like any physical conditioning or exercise program presents some unavoidable risk of injury, especially to people who have pre‐existing injuries, illness or medical disabilities.
I recognize that many changes may occur as a result of these Yoga lessons, including possible short‐term aggravation of some symptoms, feelings of tiredness, light‐headedness, increased energy, mood changes etc.
I also understand that a medical evaluation is advisable before commencing any program of physical conditioning or exercise.
I have and will continue to keep my Yoga instructor on the retreat informed of any physical condition or disability, which would prevent or limit my participation in an exercise program.
I acknowledge that, although the program may have substantial physical benefits, my Yoga instructor on the retreat is not engaged in diagnosing or treating medical diseases or deficiencies.
I expressly assume all risks of my participation in this Yoga program and waive any claim, which I might otherwise bring against my Yoga instructor on this retreat or against the operators of the retreat as a result of injuries from or relating to my participation in this program.
I confirm that all the information provided in this questionnaire is true to the best of my knowledge and I am not aware of any reason why I should not participate in this retreat or these classes.
Email
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Date
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