Your Journey Begins Here… Amogha Āyurveda Registration Form Name * First Name Last Name Email * Phone * Country (###) ### #### Gender Female Male Transgender Gender Neutral Non-Binary Pangender None of your business Date of Birth * Required for Age Verification MM DD YYYY Time of Birth For personalized Astrology Chart (optional) Place of Birth For personalized Astrology Chart (optional) Emergency Contacts * Add at least two emergency contacts. Health History Pre-existing conditions * Do you have any pre-existing medical conditions? (Please specify) Medications * Are you currently taking any medications? (Please list all medications and their dosage) Surgeries * Have you had any recent surgeries or medical procedures? If yes, please provide details. Physical health * How would you describe your current physical health? (e.g., Excellent, Good, Fair, Poor) Excellent Good Fair Poor Allergies * Do you have any allergies? (e.g., food, environmental, medication) If yes, please list the allergens and reactions. Pregnancy * Are you pregnant or planning to become pregnant during the retreat dates? (If applicable) No Yes I Don't Know Fitness level * Please describe your current fitness level: Are you comfortable participating in daily yoga and wellness activities? (If applicable) Yes No Explain Explain Fitness Level * Photo and Video Consent * I understand that during the retreat, Amogha Āyurveda may take photographs or videos that could include images of me. I hereby give consent for these media materials to be used for promotional purposes, including website, social media, and marketing materials. I Agree I Don't Agree Choose your Accommodation * Double-check your selection before submitting this form Single Shared Roommate Participants booking double occupancy will be placed with same sex only. (Only applicable for double occupancy accommodations) write your initials to agree. Agreement and Consent * By submitting this form, I acknowledge that the information provided is accurate and complete to the best of my knowledge. I understand that it is my responsibility to inform the retreat organizers of any changes to my health status before the retreat starts. I hereby give my consent for the retreat organizers to use this information to ensure my safety and well-being during the retreat. (Please type your name below)
