Pre Retreat Questionnaire

Congratulations on registering for the Kailash Ashram Retreat!

This form is here for us to learn a little about you so that we can offer a supportive space during your stay at Kailash Ashram. Your answers will be handled in accordance with our data protection policy and will not be shared with anyone on the retreat. Please answer as truthfully as possible.

Which Retreat have you booked in for? *

Full Name *

Date of Birth *

Phone *

Email *

Emergency Contact - Name *

Emergency Contact - Phone Number *

WhatsApp: We manage retreat correspondence via email and through the phone messaging app Whatsapp via a group chat. Do you have whatsapp (or will you be able to get help in installing it?) *

Location: Please enter your city and state as this will help us coordinate ride shares. *

Are you happy to offer a ride share to other participants? *

Do you require assistance with transportation to the retreat? *

Dietary Allergies: We provide a nutritious whole food, vegetarian diet that is balanced to support the activity. We are able to cater to genuine dietary allergies, please let us know below. For those Gluten Free, please let us know if you are celiac and for vegans, please let us know if ghee (clarified butter) is problematic. NOTE: We are unable to cater to individual preferences or minor intolerances. There are ample staples and fruit provided at each meal if a particular dish is not to your liking (though most students rave about our homely cooking!) *

Past Experience: Please provide an outline of your prior meditation and yoga experience (none is required!) *

Personal Goals: What are you hoping to receive from the retreat, and more broadly the practices of meditation and yoga? *

Inspiration & Motivation: What gives you energy and what are you passionate about? *

Challenges & Obstacles: What challenges, obstacles or difficulties are you facing? *

Mental Health: Are you currently suffering any diagnosed mental health illness, and if so, please describe your illness and current treatments. *

Physical Health: Are you currently suffering any physical illness or injury, and if so, please describe your injury, treatment and how this impacts you. *

Are you a tobacco smoker? Kailash Ashram is a drug and alcohol free venue. In some circumstances we permit students to smoke if they have made a genuine commitment to reducing their intake, though our preference is for you to not smoke at all. *

Addictions: Kailash Ashram is a drug and Alcohol free environment. Many students use a retreat to help them abstain from addictions / vices which is a noble intention but can mean that they suffer withdrawal symptoms during the retreat, which may cause distraction. If you wish to use a retreat to help you quit (alcohol, marijuana, smoking, vaping or anything at all, even sugar), we require you to be free for at least 7 days prior to the start of the retreat. We also ask that you disclose the addictive substances you are abstaining from so that we can support you during your stay. *

I confirm that I have read the Ashram rules and that I will abide by them for the duration of the retreat whilst at Kailash Ashram.

Indemnity Waiver: I understand that the benefits of yoga and meditation practice may vary among individuals. I acknowledge that my experience during the retreat may differ from others, and any results or outcomes are not guaranteed. I voluntarily assume all risks associated with my participation and release Kailash Ashram from any liability for personal injury, property damage, or any other loss that may occur during the retreat. To agree, please type your name and today's date in the field below *