Registration Form
Please fill in the information below in order to complete registration.
This information will allow us to ensure that you can make the most of our Programs. All personal information will remain strictly confidential.
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Email *
Program Attending *
Program start date *
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I understand that I must attend all sessions of the selected program. In case of absence, I agree to take the missed session in private. *
Personal information
First Name *
Last Name *
Date of Birth *
MM
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Gender *
Address *
City *
Country *
Postal Code *
Phone *
Emergency Contact Information
Name *
Relationship *
Phone number *
Experience of Yoga
Please give details of the types of Yoga you have practiced, how long you have been practicing and how often do you practice.
Health Information
Height *
Weight *
Please indicate if you currently suffer from, or have previously suffered from any of the following conditions:
Colonne 1
Physical limitations or disabilities
Communicable disease
Diabetes/Hypoglycemia
Heart conditions
High/Low blood pressure
Stroke
Asthma/ Respiratory conditions
Heartburn, peptic ulcer or intestinal conditions
Chronic pain
Arthritis
Osteoporosis
Seizures/Epilepsy
Spinal conditions
Anemia
Endocrine conditions
Urinary conditions
Glaucoma
Hernia (abdominal)
Surgery in the last 6 months
Injury in the last 3 years
Psychotherapy psychological therapy or counseling in the last 5 years
Treatment programme for alcohol/substance
None
Other
Clear selection
If you have checked any of the above, please give details of the nature and duration of the condition. Please specify if you are currently on any medications. For what condition(s)? If yes, please describe any known side effects of these medications (e.g. change of heart rate, lack of coordination, etc.) that may impact your yoga practice:
Women Only
Are you currently pregnant?
Allergy History
Please indicate if you currently experience any allergies *
If your answer is yes, please give details of the nature of the allergy and the treatment required in case of emergency
How did you hear about us?
*
Agreement
I hereby willingly undertake to attend this program completely. It is always important to consult your doctor before beginning a new exercise program. Make sure you always follow the teacher's instructions. As a student, you remain fully responsible for your practice, safety and well-being. The responsibility to take a posture or not, to keep it or to leave it, comes back to you. By signing this form, I release the teachers and leaders of Samsara Hatha Yoga from all liability and waive all rights to bring an action, claim and cause of action arising from my participation in this course. I will not communicate the contents of the program, either directly or indirectly to anyone else. I understand the participation guidelines and agree to follow them.
I hereby agree with the above statements and I declare that the above information is true, accurate and complete to the best of my knowledge. *
Date *
MM
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DD
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Payment
You can send the payment using Interac to patrick@samsarahathayoga.com (password: Samsara)
or PayPal at https://www.paypal.me/PatrickDesrochers

Refund Policy for Cancellations

- No refund will be provided for cancellations made within a 7 day period of the program start date
- Cancellations made within a 14 day period (and more than 7 days) are entitled to refund of 50% of the full fee minus a 10% administration and processing fee
- Cancellations made outside of a 14 day period are entitled to a refund of full fee minus a 10% administration and processing fee
- If unable to attend a workshop due to exceptional circumstances, enrolment can be shifted to a future program. Please provide a detailed explanation by email writing to patrick@samsarahathayoga.com

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