Nourish And Flourish
Registration Form
Email *
Full Name *
Address *
Phone number *
Emergency Contact Name/Relationship/Contact Info *
Do you have any special dietary requirements (vegan, vegetarian, gluten free, lactose free, etc.)? *
Do you have allergies to soaps, detergents, perfumes, etc?  Do you have any serious allergies (ie bees, peanuts) that could cause a medical emergency? *
Are you currently experiencing any problems or conditions (physical, medical, psychological, or emotional) that may affect your participation in this retreat? *
Do you take any medications on a regular basis? *
What is your goal in attending this retreat or your vision of how this retreat might benefit you in your life? *
On a scale of 0-5 (0 being no stress and 5 being extremely stressed/overwhelmed), how would you rate your mental/emotional stress? *
On a scale of 0-5, how would you rate your physical tension/stress? *
If you have any pain, would you please rate your AVERAGE daily pain on a scale of 0 (no pain) to 10 (worst pain imaginable)
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Do you currently exercise?  If so, what do you do and how often? *
What is your experience with yoga? *
I have read, understand, and accept the terms and conditions for the Deep Self Care Retreat and agree to contact Janis Freeman and/or Growing Light Wellness And Yoga with any questions or concerns.   https://docs.google.com/document/d/1T1h26-w5t5g_c5enVKXgBUJMVs3t7kGM6MUX7G4BL04/edit?usp=sharing *
Nourish and Flourish:  Come to the Catskills and bloom this Spring!
A copy of your responses will be emailed to the address you provided.
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