Medical Form

Congratulations on choosing this transformational immersion for yourself and your life.

Please take a moment to fill in your details below about your medical history, which will be strictly confidential.

Full Name

Emergency contact name, and their relationship to you

Emergency Contact Phone Inc. Int. code

Are you taking any medication?

Yes

Please elaborate here about your medication(s)..

Have you ever suffered from any of the following?

Seizures

Asthma

Heart Failure Or Stroke

Low Blood Pressure

High blood Pressure

Allergies

Diabetes

Depression

Other

Please elaborate on your answer here.

Dietary Needs

Travel Insurance Policy Number

Travel Insurance Phone Number Including International Code

I certify, warrant and represent that the information provided above is a complete and accurate statement of the physical and psychological conditions that may affect my participation in the this retreat. I agree to take full responsibility for my well being while at EAI Retreat.

I undertake full responsibility to notify should there be any changes in my health status. I have read and agree to the terms and condition of the refund policy.View terms

PLEASE NOTE: During EAI Retreat we will be partaking in daily yoga, somatic movement, dance, wáter dance, drumming and a long hike to one of Bali’s largest waterfalls. Although EVERY BODY is welcome to join EAI some level of physical fitness will make the immersion more enjoyable for you!

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