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Kaya Rao

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REGISTER INTEREST TO ATTEND A RETREAT

PLEASE COMPLETE

Please fill out the following health declaration form in order to express an interest in our retreats. Once received we will confirm a space has been held for you, subject to completing the in depth health declaration and making final payment.
Please note your health and personal information is held in strict confidentiality and is for the purpose of determining and ensuring suitability, safety and wellbeing.

Full Name

Email

Phone

Please tick all that apply, and make a careful and honest assessment * Required

I am over 18

I dont have epilepsy

I am not pregnant

I do not have cardiovascular issues or an currently being treated for this.

I dont have a history of mental health issues

I dont have diabetes

I do not take blood pressure medication

I do not take any antidepressants

I do not have severe/serious asthma

I am interested in attending the following retreat/s * Required

RETREAT 1 - 7-9 Nov (2 Night)

RETREAT 2 - 13 - 16 Nov (3 Night)

RETREAT 3 - 20-23 Nov (3 Night)

RETREAT 4 - 27-30 Nov (3 Night)

RETREAT 5 - 4-7 Dec (3 Night)

Please give details of the person referring you if you are not on our current mailing list

Today's Date

Initials

I confirm that the information given in this form is true

Thanks for submitting! We will be in touch soon

Copyright Kaya Rao 2022

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