BRONX HOLISTIC HEALING DAY RETREAT FORM Name * First Name Last Name Email * Which area of healing are you most interested in learning more about? Please select ALL that apply. Respiratory Health and Wellness Plant Herbs Ayurveda Medicine Inner Child Diet Meditation Yoga Stress Reduction Self-Care Food medicine: Fire Cider 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) * Have you done yoga before? If so, what kind and how long? Do you have any health issues that affect your mobility or are likely to cause you concern when practicing yoga? * 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 What are your goals and expectations from your retreat? * Is there anything else you would like me to know? I take full responsibility for my health and will not attend if I am sick or feeling discomfort. I am fully aware of this risk and hereby release Noble Alkhemy (Dee 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.
