2020 CJ Registration

Journey through the Chakras
Registration Form

Thank you for taking the time to complete this form - as well as registering you for the Journey with the Chakras, it helps us understand your expectations and requirements in order to safely support you on your journey

About You

* Indicates required field

Name *

First

Last

Date of birth *

Age *

Address *

post code *

Phone Number *

Mobile Phone Number *

Email *

Your Journey

I would like to join the journey beginning *

How did you hear about this journey? *

what draws you to this chakra journey? *

I wish to choose the following payment plan *

Option 1
Pay £149 deposit and 7 monthly payments of £50 thereafter
Option 2
Pay deposit in 3 instalments starting July 2020 and 7 monthly payments of £50 thereafter
Option 3
Full payment of £499, 4 weeks before start date of Journey

Experience

yoga *

meditation *

sound *

journeying *

more information eg type of yoga or mediation experience *

more information eg type of sound work or journey experience *

Medical History

Disclaimer

By submitting this form, you are confirming that the contents are true and accurate to the best of your knowledge. Please notify us of any changes to your health during the journey.

As a Dru Yoga teacher, Diane Oliver is not qualified to express an opinion as to whether you are fit to safely participate in any of her Yoga classes. You must obtain professional or specialist advice from your doctor or health professional before participating if you are in any doubt. Where you are taking part in live-streamed yoga classes, please note that Diane may not be able to see you at all times. Where you have declared a health condition, please contact her before the class if you would like to be provided with suitable modifications or adjustments. Please note, where you are taking part in a pre-recorded class, you will not be able to request specific adjustments or modifications. In all classes whether face to face, live streamed remote or pre-recorded remote, always follow the safety instructions and listen to your body. Where a movement or class is beyond your experience or ability, feels too difficult for you, or you experience any discomfort, please do not continue the movement or class. You accept liability for any injuries or harm you might sustain as a result of participating in live or pre-recorded yoga.

You take full responsibility and liability for your own health and wellbeing during the Chakra Journey and when you practise anything taught in the live or pre-recorded Yoga classes in your own time.

I confirm I have read the disclaimer *

Yes

Terms and Conditions

I CONFIRM I HAVE READ AND ACCEPT THE TERMS AND CONDITIONS *

Yes

Yoga Safety Video

I confirm i have watched and understood the safety video *

Yes

In order to comply with GDPR, it is necessary for us to check whether or not you are happy for us to retain your contact details. We only hold information when it is necessary to do so and where you have given us permission to do so.
Please note we consider submission of this form as permission to hold your information during the Journey in order to be able to send you the information and gift boxes.
All information collected on this registration form is treated as confidential and will not be shared with a third party. Data collected on this form is kept securely. Your data is kept for 7 years after your last session with us, as stipulated by our insurance company. You can find out more in our Privacy Policy.

I agree to receiving newsletters from Ros simons and Woodland Elements, I understand I can opt out at any time *

Yes No

Submit

Journey through the Chakras​Registration Form