Yoga Retreat Questionnaire Name * First Name Last Name Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name Emergency Contact Number (###) ### #### Describe your hot yoga practice (required) What does it mean to you? How often to do practice? How long have you been practicing? Tell me about your health (required) recent surgeries, illnesses, medications, chronic conditions Do you have any food allergies/intolerances/preferences (required) provide details What are your expectations for this retreat? (required) Are/could you be pregnant now or have had a baby in the past 12 months? yes no Jungle trekking and Temazcal Ceremony will be added you retreat schedule. Do you plan on attending those? Plan on attending both Plan on attending Jungle hike Plan on attending Temazcal Ceremony Don't plan on attending either Liability disclaimer & Notice (required) I consulted a physician prior to enrolling to practice yoga. Otherwise, I assume the physical risk of my own physical condition, past and current medical issues/injuries/illness or medication that may effect me onthis retreat. I understand that yoga is not a substitute for medical attention, examination, diagnosis, or treatment. I recognize that it is my responsibility to notify my teacher of any serious illness or injury before every yoga session. I will not perform any postures to the extent of strain or pain. If at any time during the class, I feel discomfort or strain, I will come out of the pose. I accept that the retreat teachers, , nor Xinalani Eco Yoga Retreat and its owners are liable for any injury , or damages to person or property, resulting from taking the class and I use the premises at my own risk. Thank you!