Your Name

Your Email

Telephone

Age

City

Which retreat would you like to attend?
 East Sussex, Feb 5-7, 2016 Peru, April 8-15, 2016 Brazil, November 2016

How is your overall heath?
 Under doctors supervision Poor Average Above Average

Heath issues: please list any illnesses or health issues. Make sure to list all present medications/treatments

Have you completed a detox programme before?
 Yes No

What level is your yoga practice?
 Complete beginner Dip in and out of practice Regular practice Advanced

What style(s) of yoga do you practice/prefer?

What would you like to accomplish by attending this detox retreat?

Preferred language of printed material
 English Español

How did you find out about the programme?