Name *

First Name

Last Name

What would you most like to get out of this weekend? *

Rest and Relaxation

Improve yoga practice

Try something new

Set new year intentions

Try/explore meditation practice

Other

Health questionnaire *

Please indicate if you are currently experiencing any of the following:

Heart Disease

Shortness of breath or chest pain

High or low blood pressure

High cholesterol

Significant bone/joint/muscle pain

Spinal pain

Other relevant medical history

Any recent injuries or surgery

Any allergies (Please include any essential oils if relevant)

Other

None of the above

Please indicate if you have been diagnosed with or received treatment for:

Asthma

Stroke

Depression

Anxiety

Cancer

MS

Rheumatoid/Inflammatory arthritis

Osteoporosis

TB

Significant infection

Other

None of the above

How did you hear about this weekend? *

Flyer

Word of Mouth

Social Media

Search Engine

Yoga Weekends

Braziers Park Website

Other

Please tick here if you DO NOT wish to be contacted by Latitude Wellbeing regarding future promotions, events or information.

Declaration *

Declaration: By ticking this box, I demonstrate understanding that all physical activity involves a degree of risk. I declare that I am in good health to participate in this activity and know of no reason not to. If at any time I am unsure of the exercise or am experiencing discomfort or pain, I will stop and inform the instructor immediately. I am responsible for and aware of my limitations to stop any activity before I become unwell or injured and I will inform Latitude Wellbeing immediately of any change in my health status. I understand that Pilates and yoga may involve hands-on adjustment and I hereby give consent for this, but am aware I can withdraw this consent at any time by informing the instructor. I understand and agree that this activity is undertaken at my own risk and I therefore waive any right for myself or any of my affiliates to seek to bring any form of legal action against Latitude Wellbeing or any representative thereof at any point. On submitting this form you will be contacted with additional information regarding the event, travel and response to any questions or comments you may have (please note this is an individual response instead of an automated email, therefore please don't be concerned if it does not arrive immediately). Please contact Hayley@LatitudeWellbeing.com with any queries. Thank you - Looking forward to seeing you on retreat!

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