Summer Cleanse - Registration Form

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Name: *

Please enter your first and last name.

Date of Birth: *

Please enter your date of birth.

YYYY

Profession: *

Please enter your current profession (yoga teacher, doctor, student, retired, unemployed, etc).

Email: *

Please enter a valid email address we can use to contact you.

Confirm Email: *

Please re-enter the previous email address to confirm it is correct.

Phone Number: *

Please enter your primary phone number.

Alternate Phone Numbers:

Optional: Enter any alternate phone numbers we may use to contact you.

Fax Number:

Optional: Enter a fax number we can use to contact you.

Address: *

Please enter your mailing address, with street number, name, city, province/state, country, and postal/zip code.

Previous Yoga Experience: *

What previous experience do you have with any kind of yoga? If none, write N/A.

Interest in Course: *

Why you are interested in taking this course?

Heard About Course: *

How did you hear about this course?

Any Health Limitations?:

Do you have any physical/psychological ailments that affect your ability to practice Kundalini Yoga?

Any Medication?

Are you taking any medication that may impact your ability to practice Kundalini Yoga? E.g. high blood pressure medication

Program Waiver

I understand that it is my responsibility to consult with a physician and/or counselor/psychiatrist prior to and regarding my participation in the Summer Cleanse Program. I represent and warrant that I am physically fit and I have no medical condition that would prevent my participating to the best of my ability in the Program. I understand that I must consistently monitor my energy and comfort, and take full responsibility for my own pacing of what I can and cannot do at this time. I understand that the program activities and homework are voluntary and that Kundalini Yoga is a non-forced, non-aggressive, non-competitive activity. I assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the Summer Cleanse Program. I understand that I have choice in what I share about myself.

I will not hold Sat Dharam Kaur ND or other instructors responsible for any injuries or actions arising out of or in any way connected with my participation in this program. I acknowledge that a risk of personal injury may be involved in any exercise or yoga program, and understand that it is my responsibility to refrain from performing any yoga postures or exercises that cause me pain or discomfort, physically or emotionally. I acknowledge that in a professional manner, physical contact may be required for Kundalini Yoga instruction.

I, my heirs or legal representatives forever release, waive, discharge and covenant not to sue or make any claims of any kind whatsoever against the Summer Cleanse Program or any of the aforementioned parties for any injury, property damage/loss, or death caused by their negligence or other acts.

I agree to the terms specified in the above waiver

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