Application

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Personal Information

Surname (required)

First Name (required)

Date of Birth (required)

Age (required)

Sex (required)
MaleFemale

Marital Status (required)
SingleMarried

City, State, Country of Birth (required)

Nationality (required)

Passport Number (required)

Knowledge of English (required)
FluentAveragePoor

Dates Interested in Yoga Retreat (required)

Address

Permanent Address (required)

Telephone (required)

Email (required)

Yoga Experience

Describe your yoga background (required)

Yoga Training

Institution

Course

Duration

Yoga Teaching

Duration

Location

Country

Ashram Life or Yoga/Meditation Retreat

Duration

Location

Spiritual Tradition

Tradition

Guru's Name

Spiritual Name

Initiation Date

Alimentation

At the retreat simple vegetarian food is served.

Please list any food items that you cannot eat

Food Allergies or Intolerances

Personal Note

Mother or Father's Name and Address

In case of emergency please notify the following person. Include name, phone no.,
email and relationship

Medical History

Do you suffer from any illness or any symptoms? If yes, provide details.

Do you have or have you ever had any mental disorder? If yes, provide details.

Do you have any addictions? If yes, provide details.

Do you currently need any medications? If yes, provide details.

Would you like to gain or lose weight? If yes, why?

Do you have any children? Pets?

What is your occupation? How many hours a week do you work?

Please list your main health concerns:

Do you have other concerns and/or goals?

At what point in your life did you feel your best?

Do you sleep well? About how many hours a night?

Do you have allergies and/or sensitivities? Please explain.

Are you involved with any healing therapies? Please explain.

Will your family and/or friends be supportive of your desire to make food/or life style changes? Please explain.

Do you crave sugar, coffee, cigarettes, or have any major addictions?

How is your mood generally? Please explain.

Do you consider yourself a compassionate person?

Do you tend to help ones in need or are you indifferent to them?

What are your motivations?

How do you see yourself in five years?

Do you consider yourself a mature person?

Do you judge people easily?

Do you consider yourself to be a happy person? Why or why not?

How are you in a group setting? Do you contribute to a better group dynamic?

How was your childhood and youth?

How is your relationship with your parents?

What would you like to change about your life regarding your relationships, character, etc?

Anything else you want to share?

I have made a deposit for the YTT through Paypal or Western Union as stipulated on the YTT Course Information page. (required)

Declaration

I (Name) , hereby declare that the information given in
this application is true and accurate to the best of my knowledge. Sembrando Semillas con
Yoga has the right to change and/or reverse any decision made on the basis of incorrect or
incomplete information.

I further understand that I need to have my own insurance as Sembrando Semillas con Yoga
will not be responsible for any accidents which may occur during the time of your stay.
Furthermore, I understand that the reservation payment is not refundable less than 30 days
before the course, I agree that eventual refunding of the reservation payment is only done by 50 % of the total amount.

Disclaimer:

I take full responsibility for my behavior, my inner experience, my health, my mental condition and my interaction with others during the course, and, according to the usual procedure, I release the organization Sembrando Semillas con Yoga, the responsible teachers, and other included parties from any liability claim.

Date (required)

Signature (required)