Retreat Registration

I am a...*

Notes: If you are a returning client without changes to your profile, you will proceed through checkout, otherwise please fill out the form completely.

Returning Clients, note your profile changes here*

Dates*

Contact Information

Name*

FirstLast

Email*

Address*

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Primary Phone Number*

Cell Phone Number

Home Phone Number

Emergency Contact Information

Contact Name*

Contact Phone Number*

Contact Relationship*

Medical History

Note: It is wise to seek your doctor's advice before beginning any health/fitness/nutrition program!

Do you have any medical condition we should be aware of?*

Yes
No

Do you have any injuries we should be aware of?*

Yes
No

Are you allergic to any medication (aspirin, penicillin, sulfa, etc)?*

Yes
No

Do you regularly take any prescription medications?*

Yes
No

Have you ever had a neck or back injury?*

Yes
No

Have you ever been knocked out?*

Yes
No

Do you have chronic back or knee pain?*

Yes
No

Do you have other physical conditions, which cause pain?*

Yes
No

Do you wear glasses or contacts?*

Yes
No

If you answered yes to any of the above, please describe:

Personal Information

Height*

Needed for surfboard, paddleboard and kayak rentals

Weight*

Needed for surfboard, paddleboard and kayak rentals

T-Shirt Size*

Roommate Request

Retreat Questionnaire

Have you attended any other VyAyr Fitness activities?*

Yes
No

Would you like to take

Surf Lessons
Stand Up Paddle Board Lessons
Both Lessons

Fitness/Goal Information

Describe Your Fitness: Include the activities in which you participate (e.g. running, hiking, walking, biking, skiing, aerobics, swimming, yoga, pilates, etc.), the frequency with which you participate in each activitiy (i.e. how often, how far, for how long), the duration of your fitness program, and any other information you woud like us to have.

Describe Your Fitness*

What is the primary focus of your current exercise program? (i.e. fitness, weight-loss, competition, sanity!)

Your Primary Focus*

Your Intention!

What do you hope to accomplish and/or learn at the retreat?

Describe your intentions, goals, and wild visions for the retreat!*

Is there any activity that you are particularly eager to experience at this retreat?*

Do you have any questions or concerns?

Please call us if you'd like to discuss any questions or concerns.

Is there anything else you would like us to know about you?

How did you hear about VyAyr Fitness?*

Payment Information

Your credit card information will be sent through our secure online shopping cart payment system. To submit payment, you can either:

Submit your credit card information through our secure shopping cart
Call your credit card information in to (415) 412-1558
Mail a check to the following address:
VyAyr Fitness for Women
3320 Octavia #8
San Francisco, CA 94123

I will be paying by*

Cash
Check
Credit Card

Are you entitled to a discount?*

Yes
No

If yes to discount, please explain *

WAIVER AND ASSUMPTION OF RISK

I voluntarily agree to this Waiver and Assumption of Risk in favor of the Owner, VyAyr Fitness, in consideration for the opportunity to receive instruction from the Owner or the Owner's employees, and/or to engage in the activities sponsored by the Owner, as follows:

I understand that there are certain risks and dangers associated with the activity and being outdoors and that these risks have been fully explained to me.

I fully understand the danger involved.

I fully assume the risks involved as acceptable to me and I agree to use my best judgment in undertaking these activities and follow all safety instructions.

I waive and release the Owner from any claim for personal injury, property damage, or death that may arise from my participation in the activities or instruction.

I am a competent adult and I assume these risks of my own free will.

I understand that all pictures taken by VyAyr Fitness are owned by VyAyr and may be used in marketing materials for VyAyr Fitness.

Please type AGREE in this box below stating that you agree to and have read the Waiver and Liability Release above.*

Retreat Options*

Name

This field is for validation purposes and should be left unchanged.

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