Booking Form. Destination & Activity * Name * First Name Last Name Email * Date of Birth * MM DD YYYY Departure Date * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * Country (###) ### #### Nationality Passport Number * Height (cm) * Weight (kg) * Clothing Size * XS S M L XL Emergency Contact * First Name Last Name Relationship to you * Mobile * Country (###) ### #### Email Address * Retreat Accommodation 1. What type of accommodation would you prefer? Single occupancy Double occupancy (shared) Quadruple occupancy (shared) Are you attending the retreat with someone else? Yes No If yes, would you like to share a room with them? Please give more details, Thank you Retreat Experience - To help us understand your experience & comfort levels it is important that you fill in the following section with as much information as possible. If the section is not relevant to your expedition then please leave it blank. If you are concerned regarding the level of ability which is required then please contact us. Please list experience relevant to yoga here. What styles have you practiced? How long have you been practicing? Please type “new to yoga” if you you have no previous experience. * Horseriding Experience - Please only write if applicable for the chosen retreat. Indicate what level you consider yourself at horse riding - beginner, intermediate,advance. It is important to understand that we use holistic approach to horseriding and it is all about connection with the animal. If you don’t feel comfortable riding it, there are many other ways that you can interact with a horse that would provide healing. * Medical Questionnaire - It is essential for us to know of any such condition for planning purposes, especially for destination retreats. The following questions have been developed to provide information that may be helpful in assisting us in any medical situation involving you. With this in mind you are requested to provide all relevant details at this time and to advise us of any changes in your health/ fitness between now and the retreat. If you are uncertain of any health matter please consult your own Doctor before booking. 1. Do you or have you ever suffered from the following? If you answer ‘yes’ to any of the questions please provide further details in the text box below. Epilepsy/fits or blackouts Yes No Diabetes * Yes No Recurrent Ear or sinus problems * Yes No Problems with mobility/ lifting/ carrying * Yes No Heart/Chest or lung problems * Yes No Anxiety/ Depression or Eating Disorder * Yes No Blood Disorders * Yes No If you have answered yes to any of the above please provide more details. Do you have Asthma * Yes No If so have you: Needed Hospital Treatment Needed Steriod Tablets Both Neither If ticked then please provide more details Have you had any operations? * Yes No Have you had any serious illnesses requiring hospital admission? * Yes No Please list any medicines you take regularly * Do you have any specific dietary requirements? * Please add any further relevant information that may affect your ability to fully participate in retreat activities Security of information and use of images. To ensure the safe running of our retreats we need to use the information given on this form. We take full responsibility for ensuring that proper security measures are in place to protect this information when it is passed to our overseas subsidiary offices and third party suppliers. Any images taken of you whilst on our retreats, and images made available to us by you, may be used by us for marketing purposes. Declaration - To the best of my knowledge and belief all information provided on this form is correct and I know of no reason(s) why I should not participate in the retreat and will not be travelling against medical advice. In signing this form I confirm that I have read and understood the Love Life Retreats Ltd. Terms and Conditions and confirm that I am willing to abide by them. I also confirm I have read and understood the payment schedule and agreed to the payment terms of this booking. Declaration - I agree * I agree Thank you! Terms & Conditions
