General Support Staff

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* These fields are required

1 Welcome

2 Choose the dates of your stay

3 Participant Info

Spiritual/Preferred Name
Cell Phone (Primary) *	Please format phone #'s as xxx-xxx-xxxx
Address
Address 2
City
State/Prov.
Zip/Postal
Country
Date of Birth
Gender
First Time? *	Yes No Is this your first visit to Yogaville?
Hatha Yoga Level
Meditation Level
Do you already or would you like to receive the Yogaville Program Guide and Program Brochures??	Yes No At this time due to COVID we have discontinued the Program Guide and all print media sent in the mail. We are hoping to start again in 2023. If you'd like to receive print media in the mail to your address please check yes.
Email newsletter	Do you already or would you like to be sent our email newsletter?You'll receive our weekly newsletter with information about Yogaville happenings and upcoming programs!
Emergency Contact Name	First, Last
Emergency Contact Phone	xxx-xxx-xxxx
Meal Agreement *	I acknowledge that buffet service with vegetarian and/or vegan only options will be provided as described below and that I will bring no animal products such as eggs, meat, or fish onto ashram grounds. What meals are included: - Dinner on arrival day - Breakfast, Lunch, and Dinner on full stay dates - Breakfast and Lunch on departure day All meals provided by the Ashram are vegetarian and/or vegan. No animal products such as eggs, meat, or fish are permitted onto ashram grounds. Thank you for understanding.
The projected dates of stay
Why do you want to participate in this program? *
Have you previously completed the LYT program? *
Please relate any relevant facts regarding your spiritual search and practices that may assist us in knowing you better
Do you snore? *
Do you take any prescription medication? *	If yes, please list the drug names and conditions for which you are taking them as well as dosage and how long you have been taking them.
I agree to bring enough medication for my entire stay and to continue the prescribed medication regimen, without alteration, during my entire stay.
Do you drink alcohol? *	If yes, how often?
Do you smoke/vape? *	If yes, how often?
Do you drink coffee?	If yes, how often?
If you have ever abused alcohol or any other drugs please provide the details, including the last date of usage *
Do you have any chronic illness or physical and/or mental conditions including back problems, allergies, etc.? *	if yes, please provide details
Have you been hospitalized for any reason in the last year? *	If yes, please tell us about it (including dates and details)
Have you ever been arrested? *	If yes, please provide details
Have you ever been convicted of a felony or misdemeanor? *	If yes, please provide details
Personal Reference 1	Please provide the name. They should know you for at least a year; please exclude immediate family members. Please notify your references that we will be contacting them shortly by phone or by email
Personal Reference 1 Email Address
Personal Reference 1 Phone number
Personal Reference 2	Please provide the name. They should know you for at least a year; please exclude immediate family members. Please notify your references that we will be contacting them shortly by phone or by email
Personal Reference 2 Phone number
Personal Reference 2 Email Address
Living Yoga Newsletter	Please send me the email newsletterSignup to receive an occasional email about program reunions, program specials, and other exciting news

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