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RETREAT HEALTH FORM AND DISCLAIMER

Please complete this form to the best of your knowledge. All information given will be treated in strict confidence and stored in accordance with the Data Protection legislation.

First Name & Surname

Email

Please TICK any health conditions below that apply to you, then give details in the 'more details' box. If none are applicable tick 'None of the above'.

Uncontrolled high blood pressure

Uncontrolled low blood pressure

Arthritis (give details below)

Diabetes

Epilepsy

Asthma

Heart problems/chest pain

Back/neck/spine Problems (give details below)

Hip/knee or joint problems (give details below)

Are you pregnant or recently given birth? (give details of trimester or when)

Fainting or fits?

Detached Retina or eye problems

Anxiety/depression/mental health

Any other conditions which affect mobility or could cause concern in you Yoga or Pilates class (give details below)

None of the above

Tick this box if you are happy to be ajusted in your yoga class (in person class only)

Please give MORE DETAILS here, or list any other conditions:

I acknowledge that I have voluntarily enrolled to participate in this retreat. I release from liability The Host and any additional teachers, for any personal injury, death, property damage or loss or any nature suffered by me as a result of participation in any activity on the retreat.

I accept that neither the instructors, nor the hosting facility, are liable for any injury, or damages, to person or property, resulting from my participation in this reatreat.

I have answered honestly & to the best of my knowledge. I agree to update my teacher of any medical changes. I agree to take full responsibility for my health during the Yoga or Pilates classes, including any injuries.

I agree to my image (photo or video) being used for marketing purposes.

Signature

Thank you for completing this form.

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