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Kaya Rao

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REGISTER INTEREST TO ATTEND A RETREAT

Please complete the health declaration form to register your interest in our retreats. Once received, we will hold a space for you, pending completion of the full health declaration and final payment.

All information is kept strictly confidential and is used solely to ensure your safety, wellbeing, and suitability for the retreat.

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 * Required

RETREAT: 1 15-17 May (2 Night)

RETREAT: 2 22-24 May (2 Night)

RETREAT: 3 5-7 June (2 Night)

RETREAT: 4 12-14 June (2 Night)

If you have not attended one of our retreats before please give details of the person who referred you.

Today's Date

I confirm that the information given in this form is true

Thanks for submitting! We will be in touch soon

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