My Information

Name*

First Last

Media Outlet*

Birth Date*

Gender*

Hidden

Group Name*

Email Adddress*

Food

Food Category*

Occasional Chicken or Fish
Occasional Fish
Vegetarian
Vegan

Food Intolerances*

yes
no

A food intolerance impacts digestion and does not involve the immune system. It is not life-threatening. If you have a Food Allergy please see below in the Medical section.

I am intolerant to:*

Wheat
Dairy
Gluten
Soy
Nightshades
Dry Beans
Corn
Other

Please list your food intolerances:*

Medical

Emergency Medical Services: The Ashram is at least one and a half hours from the nearest hospital and three hours from larger hospitals with specialized services. Because of the Ashram’s isolated rural setting, ambulance services are not always immediately available; at best an ambulance takes half an hour or longer to arrive on the Ashram site. Although the Ashram has basic first aid and a medical clinic is nearby, the clinic is only open three days per week and is without emergency service; accordingly the Ashram’s ability to respond to medical situations is limited.

Allergies*

I don't have significant allergies
I'm moderately allergic
I'm severely allergic (life-threatening)

An allergic reaction can affect the skin, gastrointestinal, respiratory, immune or cardiovascular system. In severe cases allergies can be life-threatening.

Please list each allergy and degree of severity:*

Please note: Since you have a severe allergy, we will contact you with further information.

Physical Constraints*

None
Back problems
Knee problems
I have trouble with stairs
Other

Please describe your physical constraint:*

Medical Concerns*

yes
no

Are there any current medical concerns that could affect your stay here?

Please describe your medical concerns:*

Please note: Since you have a medical concern, we will contact you with further information.

Mental Health Concerns*

yes
no

Are there any current mental health concerns that could affect your stay here? For example, are you currently on any medications or in therapy?

Please describe your mental health concerns:*

Drugs & Alcohol: Drugs and alcohol are not permitted in this program. Upon your arrival you will be asked to sign an agreement that you will not use or possess any of these substances while you are here.

Have you had or do you currently have substance abuse issues*

yes
no

Please describe your substance abuse issues:*

Please note that you will not be charged but still need to complete the "Cart Purchase" in order to register.

Comments or Special Instructions: Please email any comments or special instructions to info@yasodhara.org or call 1-800-661-8711.

Media Tour – September 2018

Please register for your stay by filling out the form below:

My Information

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Media Tour – September 2018

Please register for your stay by filling out the form below:

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