Yoga Retreat Montauk Oct 17th to 20th 2013

Registration and Waiver Form     

          Montauk                                          

Participant Information

Full Name

 

Email

 

Phone Daytime

 

Phone Evening

 

Birthday

 

Travel Dates

 

Roommate's Name (if coming with friends)

 

Address: City, State, Zip

 

 

Special Dietary Needs

 

 

Emergency Contact Name

 

Emergency Contact Phone

 

 

 

Information on Yoga Practice:

Your Experience and level

 

What Style do you normally practice?

 

How many years/months  have you been practicing?

 

How frequently do you practice per week?

 

What do you hope to get out of  this retreat?

 

 

 

Have you been hospitalized in past 6 months?

 

Physical conditions that might affect your ability to do yoga:

 

Any additional information that you would like to provide us with:

 

     

    

 

 

 

 

I agree to the following:

I agree that Yoga Retreat in Montauk from Oct 17th to Oct 20th 2013 conducted by Dilshad Keshwani and other service providers associated with this package shall not be held responsible for any damages, loss or delay.

 I agree to assume all risks associated with the trip and agree that no liability will attach to Dilshad Keshwani’s group or other service providers for any personal injury, illness, delay, loss or damage to property or health. Neither Dilshad nor her associates shall be held liable or responsible for any expenses including but not limited to lodging, meals and transportation incurred by delays or other annoying issues outside of their control. In the event of any contingency due to man-made or natural disaster, Dilshad and her associates have right to change the route and the itinerary. In case of emergency that Dilshad is unable to attend the retreat or to teach, the Yoga sessions will be taught by another teacher or teachers, who she considers qualified to replace her.

 

Yoga Retreat package price includes Yoga, accommodations, breakfasts and a farewell dinner at a set time and location, as well as sightseeing set on the itinerary. If I choose to make other arrangements or not participate in any part of the group itinerary, no part of the package price is refundable due to non-participation. I am aware that all room service in the hotel, laundry and local or   international calls from the hotel, Ayurvedic and beauty treatments and other incidentals are not included in the package price.

 

I have reviewed the program on the website and the travel tips. I understand that the amount paid by Sept 15th, is non-refundable.     In case I cannot join this retreat for any reason, I may choose to send a friend, not already registered in the program, to take my spot, with a charge of $50 as processing fee. Submission of this registration form constitutes acceptance of these terms and conditions.

I have read the above and consent herewith.

 

Print name:

 

 

Signature:                                                                                                             

Date: