"*" indicates required fields RETREAT GUEST INFORMATION FORMPlease complete this form so we can plan in advance to meet your needs. We’d like to know why you’ve booked with us so we can create a great retreat experience for you. We also need to be sure there are no medical conditions that will prevent you from enjoying your time with us. Reclaim Your Self is registered as a Data Controller with the ICO. Your personal data is treated in complete confidence and is protected according to the Data Protection Act/GDPR.1. ABOUT YOUYour name* Given names Surname Date of Birth* Day Month Year Nationality*Email* Mobile number* Country Phone Number Emergency contact first and last name*Your emergency contact must NOT be someone attending the retreat.Emergency contact phone number Country Phone Number 2. Your travelAs a Bcorp company we are committed to measuring the entire carbon footprint of each retreat. To help us to do this we need to know your travel details. We appreciate you taking the time to share these. We also need to check your travel matches our transfer options. Thank you.Your arrival flight detailsArrival date* Day Month Year Time Hours : Minutes Flight number*We can arrange airport transfers with our trusted local drivers for an additional cost. Wherever possible, we will group guests arriving on the same or similar flights to offer shared transfers. If you would like us to arrange your transfer from the airport to Malabar House, Cochin, please let us know below.* Yes please arrange my arrival airport transfer I will make my own transfer arrangements Please confirm the folllowing:* I confirm that I will arrange my tourist visa to enter India. I confirm that I will complete and submit my e-Arrival Card before arriving in India. Further details can be found on page 3 of the Welcome Pack.Your departure flightArrival date* Day Month Year Time Hours : Minutes Flight number*The retreat finishes at 10:30am on 11th November. If you would like us to arrange a transfer from Golden Haveli Hotel in Delhi hotel to the airport, please let us know below.* Yes please arrange my departure airport transer I will make my own transfer arrangements 4. INSURANCETravel insurance is essential for all of our trips. When you booked, you agreed to have travel insurance in place that covers you for all of the activities you plan to undertake on your retreat and have adequate cover for travel delay, cancellation and curtailment, medical expenses and your personal belongings. Please provide us with the details of your insurance here. Thank you.Insurance company name*Insurance policy number*5. ABOUT YOUR HEALTHThis section of the form has been designed to identify if any activity might be inappropriate, need adjusting or if you need to take further medical advice. It also gives our team the opportunity to review everyone’s needs in advance and plan accordingly.Do you have or have you had any of the following. Please tick any that apply* Allergies Stroke Cancer Diabetes Long Covid Skin problems Currently pregnant Heart attack/pains in heart or chest Pacemaker Haemophilia Hyper or hypo thyroid condition Epilepsy Back problems Asthma High blood pressure Low blood pressure Bone or joint conditions History of haemorrhage Fainting or dizziness Circulatory disorders or thrombosis None If you have ticked any of the above, please give us more details if necessary - when you experienced the condition, what treatment you had or are having etc.Are you taking any medications/?* Yes No Please let us know what medication/s you are taking6. MORE ABOUT YOUWhy did you book this retreat?* To relax and leave any worries behind for a while To have fun and meet new people To be cared for and looked after To feel physically and mentally better To reclaim myself! To improve my yoga practice To gain tools and strategies to manage stress Please tick any that applyIf you'd like to tell us more, you can do so hereIs there anything that you are concerned about?*How long you have been practising yoga and what style of yoga?*Have you attended classes with this retreat teacher before?* Yes No 7. SPA TREATMENTSPurity, one of the hotels we'll be staying at is an Ayurvedic spa resort, so we've built in a rest day while we are there. You may wish to book an Ayurvedic treatment during this time. Treatments are available at an additional cost, and we'd like to know in advance whether you're interested so the resort can ensure there are enough therapists available. Please see page 20 of the Welcome Pack for the range of treatments on offer. Payment will be made directly to the spa on the day.At this stage, we don't need to know which treatment you'd like to book, just whether you intend to have a treatment during your stay.* Yes, I intend to book a treatment during my stay. No thanks 8. YOUR CONSENTConsent* I confirm that I have read, understood and answered all the questions to the best of my knowledge.*Consent* I have obtained appropriate medical advice and/or consent for any health condition that has been mentioned above and have disclosed all information relevant to my participation in the retreat activities.*Consent* I have declared and received pre-approval for any food allergy or specialist dietary request*Consent* I acknowledge that Reclaim Yourself Retreats are not responsible for any harm caused to me for any medical conditions/allergies not declared or where I have not followed appropriate medical advice.*
