COUPLES RETREAT FORM Name * First Name Last Name Email * Which date(s) are you interested in for your retreat and how many people? What is your main reason for coming to the retreat? Food Medicine Self-Care Yoga Relaxation and Stress relief Meditation: Laughter, Mindfulness and Coloring Spiritual Other What are your goals and expectations from your retreat? * On a scale from 1 - 10, how stressful is your life/job/ currently? (10 being most stressful) * On a scale from 1 - 10, how physically active is your lifestyle? (10 being the most active) * Do you currently practice yoga? If so, what style/type of yoga and how often do you practice? * The following conditions require specific modifications to your yoga practice. Please tick if any of the following apply to you. If you tick any, please provide further details below. Abdominal disorders Arthritis (osteo/ rheumatoid) Anxiety Back pain/ problems Cancer Depression Heart conditions / disorders High blood pressure Hip problems Low blood pressure/ fainting Knee problems Nerve damage / trauma Osteoporosis Pain, stiffness, swelling Pregnancy / recent pregnancies Broken bones Surgery (in the last two years) Shoulder / neck problems Do you have any other health issues that affect your mobility or are likely to cause you concern when practicing yoga? * What aspects of yoga are most appealing to you? Physical postures Relaxation Meditation Chanting Breath work Philosophy - 8 limbs Self-Care Is there anything else you would like me to know? I take full responsibility for my health during the retreat. I am fully aware of this risk and hereby release Noble Alkhemy (Dee Davis and Dre Davis) from any and all liability, negligence or other claims arising from or in any way connected with my participation in the retreat and yoga classes. Signed: Date: Thank you! I am looking forward to connecting with you on your yoga journey.
