Registration "*" indicates required fields Your DetailsName* First Last Email* Enter Email Confirm Email Username*Your username will identify you in group discussions, choose a username that will identify you and that you will remember for logging in. Password* Enter Password Confirm Password Your username will identify you in group discussions, choose a username that will identify you and that you will remember for logging in. Emergency ContactEmergency Contact Name* First Last Emergency Contact Mobile Phone*(please include your country code)Relationship to you*About YouYour Date of Birth* Month Day Year Have you experienced Esoteric Yoga before?* Yes No General Health History*(include above any major physical or mental incidents, allergies, disease or illness and when they occurred) Current Symptoms/Conditions*Prescribed Medication & Supplements*Any injuries or operations in the last 12 months?*ConsentPlease scroll to read the following terms of agreement and check both boxes if you consent.Understanding and agreement* I consent that I understand and agree to the following: By submitting this form: I understand that Fiona Lotherington is not liable for any direct, indirect, special, incidental or consequential damages arising out of or in connection with my participation in a YOGA of STILLNESS session, now or later, including but not limited to personal or any other loss or damage caused to me while participating in a YOGA of STILLNESS session. I agree and indemnify Fiona Lotherington against all claims or liability whatsoever in respect of personal injury or any loss or damage caused to me arising out of or in connection with my participation in a YOGA of STILLNESS session. Acknowledgement and agreement* I consent that I acknowledge and agree to the following: By submitting this form: I understand that Fiona Lotherington is not liable for any direct, indirect, special, incidental or consequential damages arising out of or in connection with my participation in a YOGA of STILLNESS session, now or later, including but not limited to personal or any other loss or damage caused to me while participating in a YOGA of STILLNESS session. I agree and indemnify Fiona Lotherington against all claims or liability whatsoever in respect of personal injury or any loss or damage caused to me arising out of or in connection with my participation in a YOGA of STILLNESS session. Accuracy of information* I certify that the information I have provided is accurate and complete to the best of my knowledge.PaymentPayment for the program is via Stripe. You will be redirected to Stripe when you select the button below.Yoga of Stillness Program Investment Price: Credit Card* CommentsThis field is for validation purposes and should be left unchanged.
