Your Name (required)
Your Email (required)
Mailing Address (required)
Phone (required)
Age (required)
Profession (required)
What are you hoping to get out of this program? (required)
What are your current main health concerns (physically, mentally, emotionally)? (required) [textarea* What are your current main health concerns (physically, mentally, emotionally)?]
What are the emotions you experience most often? (required)
On a scale of 1-10, what are your energy levels like generally? (0 being the lowest and 10 being the highest) (required) [textarea* On a scale of 1-10, what are your energy levels like generally? ]
What “takes you out”? What are your patterns that keep you stuck? (i.e. self- sabotage, thinking you know it already, not willing to see things differently, victimhood... (required) [textarea* What “takes you out”? What are your patterns that keep you stuck?]
Please read the release form below. By returning this form to Melanie Phillips, you are agreeing to take full responsibility for your mental, emotional and physical well-being during and after your program. You will only be eligible to begin the program once this form is filled out and returned to Melanie Phillips.
THIS AGREEMENT made upon registration, BETWEEN: The Registrant, undersigned (hereinafter called the ‘Participant’) AND: MADHURI METHOD (hereinafter called ‘MM’) contracting on behalf of themselves and all persons to whom the Release as hereinafter contained is expressed to be granted. The parties hereby agree as follows:
MM hereby advises the undersigned Participant that if he or she has any reservations as to his or her physical, mental or emotional fitness or to the advisability of taking part in any class or program offered by MM, that he or she shall first consult a physician.
The Participant is not aware of any physical condition that would endanger the Participant’s health as a result of taking part in a Yoga program offered by MM.
The Participant has voluntarily agreed to participate in any program given by MM.
That in consideration of permission to participate in any program given by MM, the Participant for himself or herself, HEREBY RELEASES AND DISCHARGES, MM, its agents, employees, or other persons authorized by it from all claims that the Participant may have for any injury or disability (including injury resulting in death), however caused (whether by negligence on the part of MM or otherwise), sustained by the Participant and for loss of or damage (whether by negligence on the part of MM or otherwise), to the Participants personal belongings suffered at any time during the course of participation in a program of MM for any purpose whatsoever.
The participant agrees that the conditions in the Agreement shall be the conditions of any future participation in any of MM’s programs.
I agree to the terms and conditions (required) [acceptance* IagreetotheTermsandConditions]
Full Name (required)
Date (required)
