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Registration Form

Please fill in the information below to complete registration.

All information will remain confidential.

First Name

Last Name

Phone number (no dashes required)

City

Zip Code

Briefly describe your experience with yoga and meditation.

What benefits would you like to experience from doing yoga?

Do you currently have (or have you previously had) any of the following health conditions?

ADHD

Addiction

Allergy

Asthma

Anxiety

Autoimmune Disease

Bloating

Cancer

Cardiac Disease

Cervical Problem

Depression

Diabetes

Gastritis, Heartburn

Gastrointestinal Problem

Hernia

Hormonal Imbalance

Hypertension

Incontinence

Insomnia

Joint Problems

Menstrual Problems

Lumbar Problem

Migraines/Headaches

Mood Swings

Nervous Problem

Obesity

Reproductive Organ-Related Disease

Sinusitis

Skin Disease

Tinnutitis & Vertigo

Trauma & PTSD

None of the Above

(Women only): Are you currently pregnant? (please write 'Yes' or 'No').

How did you hear about me?

Do you mind if I take photographs of you during the workshop? Sometimes I use these photographs for promotional purposes.

I do not mind being photographed.

I do not wish to be photographed.

Precautions

The following people cannot do Angamardana, Surya Kriya or Yogasanas:

Women who are currently pregnant
People with serious back pain or injury
Anyone who has had a major surgery in the last 6 months
Anyone who has had laproscopic surgery within the last 6 weeks

As a general guide, always consult and follow your doctor's advice. If you have any questions please contact me at jeff@alivenyoga.com or 612-804-3385.

Release & Waiver of Liability Agreement

I have read and agree with the Release & Waiver of Liability Agreement.

Refund Policy

No refund will be provided for cancellations made within 7 days of the start date for workshops/programs in Minnesota.
No refund will be provided for cancellations made within 14 days of the start date for workshops/programs outside of Minnesota.

Payment: Please submit payment via Venmo (@Jeff-Seltz) or Zelle (612-804-3385).

Thank you for registering.

Please check your email for confirmation.

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