Client Participant
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Phone Number
*
Country
(###)
###
####
Email
*
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact 1
*
At least one emergency contact must be provided for each Client Participant
First Name
Last Name
Phone
*
Country
(###)
###
####
Email
*
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Relationship to Client Participant
*
Do You currently exercise regularly?
*
If yes, what type of exercise
How often do You exercise per week?
*
0
1
2
3
4
5
6
7+
Do You currently practice mindful movement?
If yes, how often per week?
1
2
3
4
5
6
7+
Do You currently practice meditation and if so what type/s do most often practice?
If yes, how often per week?
1
2
3
4
5
6
7+
Time you normally go to bed
Time you normally get up
Typical no. of hours of sleep
Are You currently, or could You be, pregnant?
*
Please list and provide details of any physical or mobility issues, aches, pains, injuries, surgeries, or discomforts that could affect You at any time during The Service:
Have You any medical devices e.g. pacemakers, implants or prosthetics that could adversely affect You at any time during The Service:
Please list and provide details of any mental or emotional health issues or diagnosis or treatments underway, that could affect You at any time during The Service:
Have you ever had or do you have any condition e.g. sound induced epilepsy, where you may expect to have any adverse reactions of any type during soundbaths, sound therapy or meditations if yes please provide details:
*
Are You currently on any life-saving medication?
*
If yes, please state the reason and provide proof of a doctor's consent for You to participate in The Service and all of its activities and post Service practices. You must bring any necessary emergency medications (e.g., inhaler, epi-pen) with You:
Please confirm that: 1. You attend and/or take part in The Service and its activities including any post Service practices at Your own risk, and You are responsible for Yourself 2. You attend and/or take part knowing that You are responsible to make sure You are fit and well enough to join participate in all the activities at and after The Service. 3. You have sought appropriate medical and/or psychological advice prior to arrival if required. 4. That You will tell the Coaches and/or Service providers if You are unsure of any guidance given, that You stop if You experience any pain or discomfort, and You alert the Coaches and/or Service provider if You need assistance, clarification, modifications or support at anytime during The Service.
*
We highly recommend speaking to our Coaches before booking or before attending/taking part in any Service if You have any health concerns or serious conditions. Would You like to arrange this?
*
If you require a call please book a chemistry call with the relevant Coach
If You wish, please add any further relevant information here:
Have You had any current or recent illness that may be contagious?
Please specify any dietary requirements so we can determine whether we can accommodate them:
Please detail any allergies, including food allergies:
We cannot accommodate severe or life-threatening allergies, as all the kitchens use all types of food ingredients and may contain traces of allergens and thus are considered contaminated. If this applies to you and would potentially adversely affect you we unfortunately cannot accomodate you, Please contact us and cancel your booking for a refund subject to the Terms and Conditions.
*
Please confirm You have read and understood this and that You understand and accept the risks involved:
In the event of an emergency do You consent to First Aid being administered?
*
Do You have any conditions or are You on any other regular medications that the Coaches or The Service providers should be aware of in the event of needing to administer first aid?
Confirm accurate and up to date
