Bali Retreat Registration

Please make sure you have read and understood the Retreat Cancellation Policy before completing this form.

Bali Retreat Registration Form

Thank you for registering for my Bali Retreat. Please help me to understand you and your needs. The details you provide in this form are confidential, for the sole purpose of providing you with optimal care and consideration whilst on retreat. Please take the time to complete your details fully and honestly. Note – you can write as much as you need to in the open-ended questions, as the text box expands to fit the text.

Name(Required)
Address(Required)
Date of Birth(Required)
Do you have any ongoing medical conditions or mental illness?(Required)
e.g. high/low blood pressure, diabetes, anorexia, epilepsy, depression, anxiety etc
Have you recently undergone surgery (within the last year)?(Required)
Do you have any current or recurring physical injuries?(Required)
e.g. frozen right shoulder, torn left rotator cuff, lower back stiffness etc
Are you pregnant or post-natal?(Required)
Do you have any food allergies or dietary restrictions?(Required)
Whilst in yoga or meditation poses or postures, you may be touched or physically adjusted by the teacher. This is a normal part of teaching and practice. Do you consent to this?(Required)
Have you practised yoga or meditation before?(Required)
Do you wish to subscribe to my e-newsletter?(Required)
A newsletter is emailed no more than monthly. You can unsubscribe at any time.
Do you understand and accept Momentum's Retreat Cancellation Policy, linked above?
Disclaimer / Acceptance of Terms & Conditions(Required)
This field is for validation purposes and should be left unchanged.
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