Yoga Retreat in Portugal with Eileen Muir14-20 September 2024 Registration Form * 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 Information Emergency Contact Name * First Name Last Name Emergency Contact Mobile Phone * Country (###) ### #### Emergency Contact Email * 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 Buddha Retreats, 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. By entering your name below, you are agreeing to the above Release of Liability Disclaimer. * First Name Last Name Date * MM DD YYYY Personal Retreat Intention To take full advantage of our time together during the retreat, I recommend that you set an intention for any positive changes you want to make in your practice and in your life. If you want to share your intention(s) with me in the space below, I will do my best to support you in your retreat goals. Medical, Health, and Allergy Information: 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? Travel Arrangements: Are you planning to take the complementary Airport Pick Up Van to the Retreat Centreon September 14 at 3:00 PM? * Yes No List your arrival and departures flights: * Include date, time, flight number and Airline. Additional information you'd like me to know: Thank you!
