Self-ies Retreat Questionnaire
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Name *
How did you hear about this event? *
What are your intentions for this retreat? What do you hope to achieve? *
Why this retreat? Why now? *
Room Selection (Room reservations are on a first come basis. Please note your first and second choice in the "other" section below). *
Required
Rooming Preference *
Required
Bedding Preference *
Required
If you are coming with a friend, please name the friend that you would like to room with here.
Essential oil preferences (list any essential oils you DO NOT like in "other" section below). *
Required
Dietary preferences *
Required
Do you currently have: *
Do you have any other health concerns/issues? Please answer with "None" if you have no issues. *
Please list any current medications. Please answer with "None" if you aren't using any medications. *
Do you have any special needs or accommodations? Please answer with "None" if there aren't any. *
What additional information would you like to include about yourself that you think will be helpful to the facilitator? *
My electronic signature below confirms that by choosing to participate in yoga sessions, I voluntarily assume the risk of injury. I affirm that I am solely responsible for my health and well-being. I agree to inform the facilitator of any activities or movements, which I feel could cause injury to myself. I understand that yoga and meditation are not recommended and is not safe under certain medical conditions. I do not have any physical conditions or disability that would limit my participation or preclude an activity, exercise program or meditation. Nasirah Denisse Gaines shall not be held liable for any injury, contracting CoVid19, loss or damage to property and/or persons sustained during or as a result of participation in this retreat. I agree to listen to my body and monitor myself during every activity. I understand that no specific outcome is guaranteed as a result of attending this retreat. *
Date *
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Phone number *
Email *
Date of birth *
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City and State of Residence *
Emergency contact's name (someone not on this retreat) *
Emergency contact's phone number *
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