Pancha Karma Detoxification Therapy

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1 Welcome

2 Accommodations / Pricing

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$3,800.00 – All-Inclusive with Shanti cabin single

Guests

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$3,000.00 – All-Inclusive Siva cabin single

Guests

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3 People in your group

Guest 1		First Name* Last Name* Gender* Male Female Email*
Guest 1		First Name* Last Name* Gender* Male Female Email*

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5 Participant Information

All the information entered here will be kept private. Please fill out as much as you can. Required fields have a red *

Spiritual Name
Gender *	Male Female
Birth Date *
Marital Status
Languages Spoken *
Arrival Time *
Departure Time *

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6 Contact Information

Phone (mobile) *
Phone (landline)
Address *
Address 2
City *
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Emergency Contact Info - Name *
Emergency Contact - Address *
Emergency contact - Phone Number *
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Emergency Contact - Relationship *

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7 Additional Information

Are you pregnant	Pregnant?Due to the nature of the course we cannot accept those who are pregnant
How did you hear about us? *
Have you previously visited the Yoga Farm? *	If yes, please let us know when was the last time
Sivananda TTC Graduate?	yes no
Yoga Experience *	Please describe your experience with yoga and meditation
Occupation *	Please describe your work history
Education	Please describe any formal or informal education experience.
Reasons for attending the course
Medical Issues	Enter "none" if you have no issues
Comments or Special Needs
Special Diet

8 Agreements

Terms and Conditions *	I accept the terms and conditions.All deposits and payments made to Sivananda Ashram Yoga Farm are non-refundable unless canceled within 24 hours of booking. If you need to cancel or reschedule at any time after this initial period we are happy to accommodate you; your payments will be converted to an Ashram credit which you may use for up to twelve months from the time of cancellation for either course tuition or accommodations, or both.
Email newsletter *	Please send me the email newsletter Do not send me the email newsletter

9 Help us make a difference.

$	General Donation This donation goes towards the general functioning of the ashram.

10 Security Check

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11 Payment

Payment processing fee	I agree to cover the costs of processing this registration by paying the payment processing fee. We are charged an average of 4% in payment processing fees. By offsetting a portion of these fees, you allow us to direct more of our revenue to offering life-changing programs and maintaining our beautiful property. When this box is checked, we will add 2% to your booking total. Thank you for your support..
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1 Welcome

2 Accommodations / Pricing

3 People in your group

4 Additional Programs

Participants

5 Participant Information

6 Contact Information

7 Additional Information

8 Agreements

9 Help us make a difference.

10 Security Check

11 Payment