Awareness Adventures

orange divider
spacer

Registration and Health Questionnaire

Retreat Name and Location

For international exchange rates, click here to use the Universal Currency Converter.
Enter amount $
   
Name
Street
Town
State Post Code
Country
Email
Phone
Cell Phone

How did you hear about this retreat?

Brochure Web Friend Other - Please describe:
 

Health Questionnaire

Please check all that apply. Use the line to the right for brief descriptions if needed.
Heart conditions No Yes
Recent surgery No Yes
Asthma / respiratory problems No Yes
High blood pressure No Yes
Low blood pressure No Yes
Eye problems / glaucoma No Yes
Digestion Issues No Yes
Diabetes No Yes
Depression No Yes
Anxiety No Yes
Problems/injuries with the neck, spine, joints or muscles—please elaborate No Yes
Pregnancy/Childbirth No Yes
Mobility limitations No Yes
Any other medical problems that might interfere with exercise No Yes

 

Dietary Questions

Please check all that apply. Use the field to the right for brief descriptions if needed.
Allergies to Food No Yes
Vegetarian No Yes
Non-vegetarian No Yes
Special dietary requirements No Yes
 
Please tick! * I declare that I have disclosed on this form all relevant health and medical details which may affect my ability to perform exercise and take full responsibility for attending this Health Retreat.

 

By clicking Submit, you have read and agree to the Terms and Conditions.