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LIVING YOUR PURPOSE Retreat Registration
Contact Heather Smith (
heather.smith.yoga@gmail.com
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First Name
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Your answer
Last Name
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Your answer
Email
*
Your answer
Street Address
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Your answer
City
*
Your answer
State
*
Your answer
Zip Code
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Your answer
Phone Number
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Your answer
Age
*
18 - 29
30 - 39
40 - 49
50 - 59
60 - 69
70 - 79
80 - 89
90 - 99
Emergency Contact Name
*
Your answer
Emergency Contact Phone Number
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Your answer
Faith Affiliation (check all that apply)
*
Mainline Protestant
Evangelical Christian
Catholic
Buddhist
Muslim
Hindu
Jewish
None
Other:
Required
Have you ever practiced yoga?
*
Yes
No
Do you currently practice yoga?
*
Yes
No
If you practice yoga, how often?
Your answer
What type of yoga do you/have you practiced? (check all that apply)
*
Hatha
Vinyasa
Restorative
Yin
Bikram
Ashtanga
Chair
Other:
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Do you have any health issues/physical limitations that I should be aware of?
*
Your answer
Do you have any dietary restrictions/preferences? (check all that apply)
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Gluten-free
Vegetarian
Vegan
Halal
None
Other:
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Payment Method
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Credit Card
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In Person: Cash, Check or Card
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