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Booking Form
Thank you for taking the time to complete this form - as well as registering you for this online Journey through the Chakras, it helps us understand your expectations and requirements in order to safely support you on your travels
About You
*
Indicates required field
Name
*
First
Last
Date of birth
*
Age
*
Address
*
post code
*
Phone Number
*
Mobile Phone Number
*
Email
*
Choose Your Journey
I would like to join the following journey beginning 4th November 2021
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Flowering Lotus - special edition
Budding Lotus
How did you hear about this journey?
*
FLOWERING LOTUS - special edition
£695
[early bird offer of £595 available until 5th September 2021]
I wish to choose the following payment plan
*
Option 1 - Early Bird Instalment Plan
Option 2 - Early Bird Full
Option 3 - Instalment Plan
Option 4 - Full Payment
Option 1 - Early Bird - Available until 5th September 2021
Instalment Plan - £197 deposit and 7 monthly payments of £60
Option 2 - Early Bird - Available until 5th September 2021
Full Payment - £595
Option 3 - Instalment Plan
Instalment Plan - £197 deposit and 8 monthly payments of £65
Option 4- Full
Full Payment - £695
what draws you to the chakra journey?
*
BUDDING LOTUS - mini edition
£395
i wish to choose the following payment plan
*
Option 1 - Instalment Plan
Option 2 - Full Payment
Option 3
Option 1
Instalment Plan - £157 deposit and 8 monthly payments of £32.50
Option 2
Full Payment - £395
To secure your place please make payment of deposit / full amount depending on your payment plan to Ros Simons (details to follow)
with the following reference: Your Name CJ21
Experience
yoga
*
beginner
2-3 years
experienced
meditation
*
beginner
2-3 years
experienced
sound
*
beginner
2-3 years
experienced
journeying
*
beginner
2-3 years
experienced
more information eg type of yoga or meditation experience
*
more information eg type of sound work or journey experience
*
Medical History
My general health is
*
excellent
good
manageable
Please tick any of the boxes that apply to you
*
Anxiety
Arthritis (rheumatoid)
Asthma
Auto-immune disorder (ME/MS/Lupus etc)
Back pain
Balance challenges
Blood pressure - high
Blood pressure - low
Breathing problems
Depression
Diabetes
Digestive disorders or abdominal issues
Epilepsy
Glaucoma
Heart condition
Hiatus hernia
Hip problems
Hypermobility joint syndrom
Inguinal hernia
Knee problems
Migraine / headaches
Osteo arthritis
Osteoporosis
Pacemaker
PTSD
Sensory disorder affecting eyes or ears
Shoulder / neck problems
Spinal injury
Spinal disc hernia
Please list any medication you are taking and why
*
have you have any surgery in the last 2 years?
*
no
yes
If yes, please give more information
*
have you ever been diagnosed with cancer?
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no
yes
if yes, please give more information
*
are you/ could you be/ have you recently been pregnant?
*
no
yes
any further health considerations
*
eg. old injuries which still trouble you or anything not already covered which might be adversely affected by yoga practice
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 have declared a health condition, please contact her before undertaking the class if you would like to be provided with suitable modifications or adjustments. 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
Terms and conditions are found at https://www.woodlandelements.co.uk/chakra-journey-terms.html
Yoga Safety Video
I confirm I have watched and understood the safety video
*
Yes
Woodland Elements yoga safety video link https://youtu.be/MRQAleuHICw
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
Home
Yoga
Book Now
Yoga Classes & Workshops
>
Watch Anytime
>
Dru Yoga Directory
Shakti Flow Directory
Journey through the Chakras
Customise Your Yoga
Yoga is for Everyone
>
Dru Yoga
Shakti Dance
Sound
Book Sound
Blog
About
Small Print
>
Privacy & Cookies
Safety
Terms and Conditions
Get in Touch
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