Program Registration Form

Program Name: ……………………………………. Start Date: …………………………… End Date:……………………………

First Name: ................................................................. Last Name:...................................................................

Name you prefer to be called:.............................................................. Age: ………….Gender: Female/Male

Education Qualification:....................................................Occupation.............................................................

Residential Address:...........................................................................................................................................

City...............................................State, Country ..................................................Zip/Postal Code..................

Mobile Number:.................................................. Email: ...................................................................................

Emergency Contact Name, Relationship and Phone Number: ………………………..............................................

………………………………………………………………………………………………………………………………………………………..

How did you come to know of this program: ....................................................................................................

Please give details of yoga or meditation you have practiced and how long you have been practicing:

.............................................................................................................................................................................

Have you learnt any other Isha Yoga practices? Yes / No. If yes, please give details below:

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Please indicate below if you currently or previously have had any physical or mental ailments.
For Ex. Hernia, Neck or Back disease, Dislocations, Joint replacements, Injury, Depression, Anxiety etc.
Please give details of the nature and duration of the condition and if you are currently undergoing any
treatment:
.............................................................................................................................................................................
For women, Are you currently pregnant? Yes/No

Have you had any major surgery in the last six months? Yes / No

I hereby willingly undertake to attend this program completely. I take full responsibility for the result
and indemnify the organizers against all claims and suits. I will not communicate the contents of the
program, either directly or indirectly to anyone else. I understand the participation guidelines and
agree to follow them.I hereby declare that the above information is true, accurate and complete to the
best of my knowledge.

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Date & Place Signature