REGISTRATION FORM ITALY YOGA RETREAT, 24 SEPTEMBER- 2 OCTOBER,

2011

Name:  ______________________________________________ 

Age:_________________ 

Address:________________________________________________________________

City:___________________________________________State:______Zip:___________

Phone (H):__________________________(C)__________________________

E-mail address: 

____________________________________________________________ 

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Do you have previous yoga experience?_____ If so, how long? ______________ 

In what style/s?  Level

____________________________________________________________ 

How often do you practice yoga/take classes?______________________________ 

Will you be attending the yoga classes on this retreat?_______________________ 

Do you have any current injuries, health conditions or chronic pain that may effect your

comfort/participation during yoga classes?  If yes, Please explain. Use the back of this

paper if necessary. 

________________________________________________________________________

 

________________________________________________________________________

Please check any conditions that apply: 

___Diabetes    ___Hypoglycemia  ___Chronic Headaches 

___Asthma    ___Ulcers   ___Low Blood Pressure 

___Herniated/Bulging Disc ___Epilepsy ___Depression  ___Rheumatoid Arthritis 

___Hernia    ___Sciatica   ___Scoliosis (what type)  

___Hypertension   ___High Blood Pressure ___Digestive Disorders 

___Heart Disease   ___Osteoarthritis  ___Immune Disorder 

___Spondylolisthesis/lysis ___Allergies (food/meds)___Mental Illness 

  

Any other health conditions or surgeries you have had that may affect your retreat? 

________________________________________________________________________

________________________________________________________________________

Is there anything you would like us to know about your current mental or emotional

state?

________________________________________________________________________

________________________________________________________________________

Are you currently taking any medications? If so, please list below. 

________________________________________________________________________

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Accommodation:  Would you like a quad, double or single room?___________________ 

Do you have a chosen roommate? If so, who?__________________________________ 

If not, do you want us to find you one? _____ If yes, we will choose one of same gender. 

If this is not possible, you will be provided a single room accommodation.

Do you have any food allergies or special diet considerations we need to accommodate?

Vegetarian meals are only provided if requested beforehand, as the chef needs to know.

________________________________________________________________________

________________________________________________________________________

What are your goals and expectations regarding this retreat? 

______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

  

Please list 2 emergency contact people:

First contact:  Name_____________________________________________ 

PhoneNumbers:___________________________________________________________

Relationship:___________________ 

 

Second contact:  Name_____________________________________________ 

Phone Numbers:______________________________________________________

Relationship:______________________

Please send this completed registration form along with your deposit (50% of total cost)

to:

Danielle Diamond

31 Prescott

Montclair, NJ 07042

Checks made payable to Danielle Diamond.

Remainder of the balance is due July 1, 2011.

Please read the liability waiver below, sign and date. 

RELEASE

Danielle Diamond and Ali Campbell  (herein after referred to as “Agents”) act only in

capacity as agents for the participant in all matters connected with hotel accommodations,

sight-seeing journeys and transportation, whether by rail, bus, motorcar, boat or any other

means and as agents hold themselves free of responsibility for any damage occasioned by

any cause.  Agents will not be responsible for any damages or expenses or

inconveniences caused by late departures or change of schedule, strikes or to their

conditions, nor will be responsible for loss or damage to baggage or any of the

participant's belongings. All prices quoted are correct at time of printing, include the cost

of operation of the journeys, and are subject to currency changes.  Agents shall not be

responsible for personal injury, death, accident, delay, loss, damage, irregularity or

property damage as a result of force majeure or for any other losses or damages incurred

by any person or journey participants caused by any delay or change of itinerary or

arising out of any act, including, but not limited to, any act of negligence, any person

acting for or on behalf of Agents for transportation, accommodation or sight-seeing

provider or any other person or entity rendering any of these services or accommodations

  

being offered in connection with this journey.  This agreement supersedes all previous

oral or written communications, representations, or agreements between the parties.

__________________________________________  __________________

Signature        Date

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