Registration for the weekend retreat 11-13/11

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The following information is strictly for the confidential use of the retreat teacher, Susie Jones. Please answer these questions fully to enable her to guide you appropriately.

Name *

Email address *

How did you hear about this retreat? *

Directly from Susie (in person, mailing list, email etc.)

Yogaroots website

Facebook

Friend

Another teacher, therapist or centre

Other:

Have you been on a retreat before (weekend or longer)? Please give details *

Have you already taken classes with Susie ?

Yes

Other:

Clear selection

At the retreat centre there are a small number of single rooms, most rooms are doubles, there are some triples (all have single beds). Priority will be given to those who might need a single room for health reasons. Please indicate here your needs and preferences.

Single room (for health reasons)

Single room (preference)

Double room (preference)

Double room (if no singles available)

Triple room (preference)

Triple room (if nothing else available)

Please indicate if you are coming with a friend, partner or family member

Yes

Yes, and we would like a room together

Maybe

Clear selection

The meals are healthy, vegetarian and cooked on-site. Do you have any specific dietary requirements or allergies?

We would like to organise car-sharing to and from the retreat centre in Dongelberg. Please indicate if you are potentially interested in this either as a driver or as one needing a ride.

yes, I can offer spaces in my car

yes, I would need a ride

Other:

Clear selection

Do you have any history of physical illness or any disabilities, which may significantly affect your sitting, standing, or walking practice?

Have you ever been diagnosed with or experienced any significant mental health issues, e.g. depression, eating disorders, anxiety, trauma, addictions, drug/alcohol abuse? If yes, please give details of condition(s) and date(s). Please mention any medications currently being taken.

Describe any present circumstances that might place you under additional stress or may significantly affect your practice (e.g. loss, bereavement, relationship breakdown, etc.)

To support ourselves and each other during the retreat there will be periods of silence, and a request not to use electronic devices such as mobile phones during the weekend (unless there is an emergency).

Do you agree?

Yes

The registration fee of 150 euros per person covers the basic costs of renting the retreat centre for the weekend (room and all meals included).

None of this goes directly to Susie, so you are asked to make a financial contribution for the teachings and guidance she will offer during the retreat.

Do you agree?

Yes

Health safety: we will respond to any changes in the Covid situation that may arise. We request that participants do a quick test at home if they are experiencing any symptoms prior to the retreat and to not come if they have tested positive.

Do you agree?

Yes

Cancellation policy:

Before 28 October full refund minus 20 euros admin fee

Between 28/10 and 8/11 refund of 50 euros

After 8/11 there is no refund

Exceptions will be made to anyone testing Covid positive in the days before the retreat.

Do you agree?

Yes

Disclaimer: Do you agree to take full responsibility of your physical and mental health during the retreat? *

Yes

Is there any additional information you would like to convey to the teacher or any question ?

Submit

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