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“INNER WORLDS” RETREAT  2018 -  REGISTRATION FORM
 
GENERAL INFORMATION
 
Name (as it appears on your passport)
 ______________________________________________________________

Address_________________________________________________________

City _________________________State _________ Zip code _____________

Phone (home) _______________________( cell) ________________________

E- Mail address ___________________________________________________

Age _____ Gender: M ____F___ Occupation __________________________
 
EMERGENCY CONTACT PERSON
 
Name ________________________________City and State___________________
 
Daytime phone _____________________Evening Phone ______________________
 
Cell phone ____________________________Relationship to you________________
 
 
 
YOGA BACKGROUND
 
How long have you practiced Hatha Yoga? ________
 
Which style of Hatha Yoga are you accustomed to? _________
 
Do you practice daily Meditation?   Yes _______ No _________
 
If yes, for what duration each day? _________
 
 
HEALTH RECORD
 
Have you had or do you now have:   (please circle if so)
 
                                                                                                                
Frequent sore throats/colds                                                                                                         
Difficulty sleeping
Rheumatic fever                                                                                              
Earaches                                                                                                                           
Bronchitis                                                                                                           
Cancer
Tuberculosis                                                                                                       
Hepatitis                                                                                                             
Heart trouble or BP
Mononucleosis                                                                                                               
Frequent indigestion                                                                                                  
Epilepsy                                                                                                              
Back problems
Hernia                                                                                                                   
Fainting spells
Dermatitis                                                                                                         
HIV or AIDS
Stomach ulcer                                                                                                    
Eating disorder
Kidney trouble                                                                                                 
Car sickness
Diabetes                                                                                                             
Obesity
 
Any others? (If so, what?)___________________________________
 
Please describe details of any you circled on the back of the third page.
 
Have you been under the care of a hospital in the last two years?   Yes ____No_____
 
Hospital__________________________Disease________________Year__________
 
Hospital__________________________Disease________________Year__________
 
 
Have you ever been institutionalized for any mental disorder, nervous break-down,
 etc., or been under the care of a psychiatrist? Yes _______No ____
 
Have you ever had a serious injury ? Yes _______No ____
(if yes, specify)___________________________
 
Are you currently taking any medications? Yes ___________No ____
 
(if yes, specify)_________________________________________________________
 
 
Agreement
 
I agree to abide by the guidelines of the tour program, which include following a lacto-vegetarian diet and refraining from the use of alcoholic beverages, cigarettes or recreational drugs during the duration of the tour. I certify that I am in good health and have no physical or mental ailments, except as may be indicated on this application. I further agree to assume full responsibility for any injuries, losses or damages that may occur to me or my property during the tour.
 
 
 
Signature ________________________________Date____________________
 
If you wish to submit the registration form by post, please mail to: 
 
Swami Divyananda
108 Yogaville Way
Buckingham, VA  23921
 
FEES AND DEPOSIT
 
The total fee for retreat is $650. The deposit required by September 15, 2018 is US $300. The second payment of $350 can be paid at the beginning of the retreat.  
 
Do you wish for single room accommodation?  Yes _____ No _____  
The supplement for a single room is $200.
 
Checks are to be made out to Sacred India Tours (even though it is for the retreat – your checks will go into the tour bank account).  Please post to:
 
Swami Divyananda
108 Yogaville Way
Buckingham, VA  23921
 
If you prefer to pay by credit card please contact us to make arrangements.
Thank you.
 
OM Shanthi, Shanthi, Shanthi
 

 
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