Wiveton Hall Yoga  Booking Form & Health Questionnaire
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Email *
Date of Wiveton Hall Retreat you are attending *
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Name *
Address *
Phone Number *
Date of Birth *
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At what level is your yoga practice? *
Required
Which type of room would you prefer? *
Required
Are you traveling alone or do you know who you wish to share with?
If traveling with a friend what is their name?
Do you or have you suffered with a heart condition? *
Required
If you answered yes please add details
Do you feel pain in your chest during physical activity? *
Required
If you answered yes please add details
Have you had chest pain in the last month when not doing physical activity? *
Required
If you answered yes please add details
Do you ever lose consciousness or do you lose your balance because of dizziness? *
If you answered yes please add details
Do you have a joint or bone problem that may be made worse by a change in physical activity? *
If you answered yes please add details
Are you currently taking any prescription medication for blood pressure or heart condition? *
Required
If you answered yes please add details
Are you pregnant? *
Required
If you answered yes please add details
Do you have insulin dependent diabetes? *
Required
If you answered yes please add details
Do you know of any other reason you should not exercise or increase your physical activity? *
Required
If you answered yes please add details
Do you have any food allergies or dietary requirements? *
Required
If you answered yes please add details
How did you hear about this retreat?
I hereby agree to indemnify and hold harmless L Dunn & P Reynolds from and against liability, damages, costs, loss or expense (including without limitation, legal fees) arising out of any bodily injury, at any time sustained by the undersigned. Yoga is no substitute for medical diagnosis and treatment; that yoga practice and/or specific poses are not recommended for individuals with certain conditions (e.g., cardiac illness, later stages of pregnancy, post-surgery); and that the student assumes the risk of yoga practice and releases the teacher and studio from any liability claims.
I agree
Payment Terms & Conditions: A non-refundable deposit of £100 is required to secure your place, the remainder is due no later than 6 weeks before the start of the retreat, for which you will receive an invoice. If payment is not received 6 weeks prior, your place may be offered to another. In the event of you cancelling: 60 days or more prior to the retreat: Your entire payment will be refunded, less £100 which is your deposit. If you cancel 59-30 days prior to the retreat: payments are not refundable but are transferable (less £100 deposit) to a future retreat. And if it is 29 days or less prior to the retreat: payments are not refundable.
I agree
For deposit and full payment please transfer funds to the bank details below using the reference - Wiveton Retreat:  Lisa Dunn - Sort Code: 23-14-70 - Account Number: 66089515.
If you would like any more information please contact Lisa at lisa@lisadunnyoga.com or 07967 997 453
A copy of your responses will be emailed to the address you provided.
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