Ayurveda & Yoga Immersion Registration Information Form

Email*

Name*

Occupation*

Address*

Home Phone*

Business Phone*

Cell Phone*

Please select how you would preferred to be contacted, if needed*

Home Phone

Business Phone

Cell Phone

Please select from the following:*

In Person Option

Online Option

Date of Birth*

Age*

How did you hear of our program or who were you referred by?*

Emergency Contact*

Emergency Contact's Phone Number*

What is your previous experience with yoga and/or Ayurveda?*

Why are you interested in taking this program?*

What is your experience with stress management techniques or meditation?*

What is your current exercise/yoga program?*

What is your physical condition? Please list any medications you are taking.*

What do you foresee as being challenging for you, and how may we best support you?*

How do you foresee yourself integrating this training into your life?*

What do you expect to attain from taking this program?*

How often per day do you consume caffeine?*

How often per day do you consume alcohol?*

How often per day do you consume tobacco?*

How many hours of sleep do you get on a typical day?*