Application for Admission

Please mark any medical condition(s) past/present:

AnxietyAsthmaBack ConditionBi-Polar Disorder

CancerChronic FatigueDepressionDiabetes

MigrainesEpilepsyFibromyalgiaHeart Condition

High/Low Blood PressurePregnantPTSDOther

Please read and sign by typing your name & date below:

I accept responsibility for my own health and safety. I relinquish meditation chick, all elements yoga and instructors from all liability. $500 non-refundable deposit is due to reserve my space. I understand and accept that early bird pricing of $1800 must be paid on/before June 27, 2018. After June 27, course fee is $2000. All course fees must be paid in full by September 10, 2018.

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