GUEST FORM - Trainings at La Roane Retreat Center

Please fill in the form below in as much details as possible. All information will be treated as confidential, and is used to ensure your safety and well-being during the training.

Name

First Name

Last Name

Phone

Country

(###)

###

####

Are you taking any medication?

Do you have any side effects from this medication?

Please give a brief description of your yoga practice and experience

Do you have or have you had any of the following? If yes, please provide details.

High or low blood pressure, heart palpitations, heart disease, varicose veins, deep vein thrombosis, chest pain, glaucoma, anemia, asthma, bronchitis or pneumonia, sinusitis, ear infections, covid-19, nausea, digestive issues, acid reflux, auto-immune disease, frequent colds or flus, fatigue or exhaustion, dizziness, diabetes, cancer, scoliosis, herniated disc (incl. location), injuries or fractures (incl. location), recent accidents or falls, lower back pain, general back pain, hip pain, joint pain, headaches, migraines, epilepsy.

Do you have or have you had any of the following?

Anxiety, depression, or similar mental health conditions

Are you pregnant?

Do you have any specific dietary requirements (e.g. intolerances, allergies etc.)?

Please provide details for an emergency contact person (name, relation, phone number, email address)

Please give an indication of your travel plans to the training centre (La Roane), if you require a pick-up, and expected arrival time

Is there anything else that you would like to share with us that you think might be relevant?