Womens Retreat
Participant Information

Participant information we gather from you is to help myself Katy from The Heart Space and Emily from
Sulis Botanicals to guide you through the day in the safest possible way.

All the information you share with us will be kept in the strictest of confidence.

By SUBMITTING this form informs us that you have given truthful information to enable us to fully support your day - Thank You!

From our hearts to yours, we look forward to welcoming you to this magical retreat day.

Katy & Emily xx

Name

First Name

Last Name

Email

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Details:

please add thier phone number, name and relationship to you:

Are you following a specific diet:

vegetarian

vegan

lactose free

dairy free

gluten free

N/A

Do you have any allergies?

please list allergies below:

Current Medications

This is so Emily can be aware of any potential drug/herb interaction with the forage walk and any other offers she has for the day: (please also state if you are not on any medication)

Some of the herbal formulations we will be tasting contain alcohol (although each drop is no more than what is in a slice of bread)

Please tick if this is ok?

yes

no

Do you currently have any injuries, aches, or areas of tension or discomfort in your body?

please list anything you're aware of to help Katy fully support your yoga practice:

Are there any specific body parts or joints you'd like extra support with during your yoga classes?

eg knees, lower back, hips, shoulders, neck:

Do you have any current or past conditions that may affect your movement or balance?

such as arthritis, sciatica, osteoporosis, hypermobility, etc:

Is there anything else you'd like to share that would help us support you during the retreat?

Womens Retreat Participant Information

THE HEART SPACE

Womens Retreat
Participant Information