CONTACT INFORMATION :
LAST NAME FIRST NAME
ADDRESS
CITY STATE ZIP
EMAIL ADDRESS (We respect your privacy. We will never share your information to anyone or to any organization).
CELL PHONE HOME PHONE WORK PHONE
AGE
PROFESSION
MARITAL STATUS
GENDER
Under physician's care? Yes No If yes, for what reason?
Epilepsy? Yes No
Diabetes? Yes No
Are you currently seeking mental health care? Yes No If yes, for what condition?
Please list any current medications:
Do you have any dietary requirements?
What is your past history with yoga practice?
Which program are you registering for? Stationary Sequence Vinyasa Please take a moment to write down what you want out of this intensive experience. There is a power in writing down goals, sharing them and then referring to them often. It is suggested that you do the above practice in preparation for this week. At the very least, please share your goals for this experience with us now so we may better support you during the intensive.
How did you hear about the retreat? Please include the name of anyone who referred you.
Please call Empowered Yoga Wilmington Center at 302.654.YOGA after clicking SUBMIT button to make payment and finalize registration.
