Vitox Vikasa Retreat Application Form

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Your Name(Required)
*FIRST NAME *LAST NAME
*AGE(Required)
*DATE OF BIRTH(Required)
*EMAIL ADDRESS(Required)
LIFESTYLE AND GOALS
*WHAT ARE YOUR MAIN HEALTH CONCERNS?(Required)
*ANY OTHER CONCERNS AND/OR GOALS?(Required)
*HOW WOULD YOU RATE YOUR PHYSICAL HEALTH ON A SCALE OF 1-10?(Required)
*HOW WOULD YOU RATE YOUR MENTAL HEALTH ON A SCALE OF 1-10?(Required)
*IS STRESS CURRENTLY AN ISSUE IN YOUR LIFE, IF SO, HOW?(Required)
*HOW IS YOUR SLEEP? HOW MANY HOURS DO YOU SLEEP PER NIGHT?(Required)
*DO YOU HAVE ANY REGULAR HOLISTIC THERAPIES?(Required)
*HOW MANY TIMES A WEEK DO YOU EXERCISE?(Required)
*HAVE YOU DONE YOGA BEFORE? IF SO, FOR HOW LONG AND HOW FREQUENTLY?(Required)
*HAVE YOU DONE MEDITATION BEFORE? IF SO, FOR HOW LONG AND HOW FREQUENTLY?(Required)
*HAVE YOU WORKED WITH A LIFE COACH OR HEALTH COACH BEFORE?(Required)
FOOD AND WELLNESS
*WHAT IS THE MOST IMPORTANT THING YOU WOULD LIKE TO CHANGE ABOUT YOUR DIET TO IMPROVE YOUR HEALTH?(Required)
*WHAT WOULD A TYPICAL DAY OF EATING/MEALS LOOK LIKE FOR YOU?(Required)
*DO YOU HAVE ANY CRAVINGS OR ADDICTIONS YOU WANT TO ADDRESS?(Required)
*HAVE YOU DONE A DETOX BEFORE? IF SO, HOW LONG AND WHAT KIND?(Required)
*DO YOU HAVE ANY FOOD ALLERGIES OR SIGNIFICANT LIKES/DISLIKES?(Required)
MEDICAL
*ANY CURRENT OR PREVIOUS SERIOUS ILLNESSES, HOSPITALIZATIONS, OR INJURIES?(Required)
*ANY ALLERGIES OR SENSITIVITIES?(Required)
*LIST ANY CURRENT SUPPLEMENTS OR MEDICATIONS YOU ARE TAKING:(Required)
ADDITIONAL COMMENTS/ANYTHING ELSE YOU WOULD LIKE TO SHARE?
Personal Programs | Agreement of Release and Waiver of Liability
(Required)
- I represent and warrant that I am in good health and do not suffer from any medical condition which would limit my participation in the Personal Programs offered at Vikasa. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Personal Programs, including any of the yoga classes, programs, workshops, guest excursions or other treatments offered.
(Required)
- I acknowledge that the services provided in the Personal Programs do not constitute medical advice and are limited to lifestyle and wellness matters. I understand the risks associated with all activities offered at Vikasa, and I agree to follow all instructions so that I may safely participate in classes, workshops & all other activities.
(Required)
- If I am pregnant, become pregnant or am post-natal, my signature verifies that I am participating in all activities with my doctor’s full approval. I realise that I am participating at my own risk.
(Required)
- I hereby WAIVE AND RELEASE Vikasa, its owners, employees and instructors from any claim, demand, cause of action of any kind resulting from or related to my participation in the Personal Programs.
(Required)
- In taking part in the Personal Programs, including the yoga classes, workshops & all other activities, I understand and acknowledge that I am fully responsible for any and all risks, injuries, or damages, known or unknown, which might occur as a result of my participation.
(Required)
- I have read the above release and waiver of liability and fully understand its content. I am legally competent to sign and voluntarily agree to the terms and conditions stated above.
Please practice mindfully and enjoy the many benefits of undertaking yoga and wellness practices with Vikasa.
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Vitox Vikasa Retreat Application Form | Vikasa

Vitox Vikasa Retreat Application Form

LIFESTYLE AND GOALS

FOOD AND WELLNESS

MEDICAL

Personal Programs | Agreement of Release and Waiver of Liability

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