Registration Form – Yoga Suraksha

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Program Registration

Thank you for your interest. Please fill in your details to get started.

Program Name

Start date

End date

First Name *

Required field

Last Name

Age

Gender Male Female

Education Qualification

Occupation

Your Mobile Number *

Required field

Your Email Address *

Valid email required

Emergency contact name

Emergency Contact Number

Relationship *

Required field

Residential Address

State

City *

Required field

PIN Code

How did you come to know of this program?

Have you learnt any other Isha Yoga practices?

Yes No

Please indicate below if you currently or previously have had any physical or mental ailments. For Ex: Hernia, Neck or Back disease, Dislocations, Joint replacements, Injury, Depression, Anxiety etc. Please give details of the nature and duration of the condition and if you are currently undergoing any treatment:

For women, Are you currently pregnant?

Yes No

Have you had any major surgery in the last six months?

Yes No

I hereby willingly undertake to attend this program completely. I take full responsibility for the result and indemnify the organizers against all claims and suits. I will not communicate the contents of the program, either directly or indirectly to anyone else. I understand the participation guidelines and agree to follow them. I hereby declare that the above information is true, accurate and complete to the best of my knowledge.