DESIGNING EXPERIENTIAL WORKSHOPS

REGISTRATION FORM

(Please send this form with your payment to Discovery Yoga, 142B King Street, St Augustine, FL 32084.)

Name__________________________________________________________________________ 

Address________________________________________________________________________ 

City_____________________________________State _________________Zip_______________

Telephone (home)_____________________________________(other)______________________

email___________________________________________________________________________

c ENCLOSED IS MY CHECK FOR $200. c PLEASE BILL MY CREDIT CARD:

Account #______________________________________________ Exp Date__________________

Yoga Teacher Training or other relevant education:_____________________________________ 

_________________________________________________________________________________ 

How did you find out about this program?_______________________________________________

The following information will help your instructor to better support you in the workshop:

c Female c Male Age:__________ Describe your present state of health:______________ 

Please check and clarify any of the following conditions that apply to you:

c Allergies:

c Arthritis:

c Asthma:

c Chronic sinus condition:

c Diabetes:

c Endocrine conditions:

c Epilepsy:

c Glaucoma:

c Hernia:

c Hypoglycemia:

c Heart conditions:

c High blood pressure:

c Low blood pressure:

c Intestinal conditions:

c Osteoporosis:

c Recent injuries:

c Recent surgery:

c Spinal conditions:

c Ulcers:

c Urinary conditions:

WOMEN:

c Menstrual conditions:

c PMS symptoms:

c Pregnant:

c Hysterectomy:

c Menopause symptoms:

c Peri-menopause c Post-menopause

Describe any other physical or mental conditions that would be helpful for your instructor to be aware of.
(Use back of page if necessary.)

I certify that the above information is true and complete to the best of my knowledge and that I will not hold Discovery Yoga Inc. or my instructor liable for any mishaps arising from my participation in yoga class.

Signature_______________________________________________Date_______________ 

Discovery Yoga, Inc. is a member of a network of yoga studios spiritually affiliated with Kripalu^® Center for Yoga and Health, Lenox, MA. This yoga studio, like all Kripalu affiliated yoga studios, is independently owned and operated. Kripalu Center for Yoga and Health is neither responsible nor legally liable for the activities conducted at this yoga studio.