2025 Italy Yoga Retreat with Eileen Muir8-14 September 2025Registration Form Name * First Name Last Name Email * Mobile Phone * We use WhatsApp to communicate before and during our retreat. Enter the mobile phone you will be using at the retreat. Country (###) ### #### Emergency Contact Name * First Name Last Name Emergency Contact Mobile Phone * Country (###) ### #### Emergency Contact Email * Terms & Conditions Terms & Conditions * I have read and agree to the Terms & Conditions for the Retreat Contract. Yes Acknowledgement and Assumption of Risk and Release THIS DOCUMENT CONTAINS A RELEASE OF LIABILITY. I understand and agree that travel to a foreign country and related activities that I have chosen to take and engage in with Eileen Muir may carry risk. I agree that I am responsible for my safety while participating in activities undertaken with Eileen Muir, and specifically acknowledge that the following persons or entities, including Eileen Muir, employees of Anuttara Yoga Retreat Center, and affiliates of any person named above ARE NOT RESPONSIBLE FOR MY SAFETY. By signing this Acknowledgment and Assumption of Risk I acknowledge that I understand that any and all risk is expressly assumed by me, and all claims are expressly waived in advance. Digital Signature By entering your name below, you are agreeing to the above Release of Liability Disclaimer. * First Name Last Name Date * MM DD YYYY Relevant Medical History List any Relevant Medical History that may affect your participation during the retreat: * List any medications you take and the purpose of each medication: * List any physical injures or limitation(s) that prohibit or limit your participation in yoga class. Please specify which postures exacerbate your limitation(s) and what makes it feel better: * Allergy and Dietary Restrictions: List any allergies: * List all dietary restrictions: * Yoga & Lifestyle Questions: How long have you been practicing yoga? How many times a week do you practice and for how long? How many classes a week do you take? Additional information you'd like me to know: Thank you!
