Let Go & Flow:Intake Form Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Please list any medical conditions we should be aware of (physical or mental health) Please list any medications you are prescribed Please advise of any relevant injuries, surgeries, or limitations Please advise if you require any accommodations Please list any food allergies, sensitivities and dietary restrictions. If you are anaphylactic, please make note of a safety plan (e.g. location of Epi-Pen) Please list any environmental allergies, sensitivities, and intolerances, including to scents (e.g. bee stings, essential oils, incense, etc.) Is there anything else we should be aware of? How did you hear about us? Google Social Media Word of Mouth Other I consent to being photographed or recorded during events for promotional use by Lumi Yoga and its affiliates. * Yes No Acknowledgement & Waiver of Liability * By clicking the checkbox below, I agree and understand that: I am participating in Let Go & Flow: Yoga & Wellness Retreat, taking place October 17-19, 2025, on own behalf and of my own free will. I understand that retreat activities may include but are not limited to: yoga, meditation, sound baths, nature hikes, sauna use, swimming, kayaking, and wellness workshops. This retreat is a wellness retreat. It is not psychotherapy, counselling, or mental health treatment. None of the facilitators or organizers are providing medical, psychological, or psychiatric services through this event. If you are experiencing or develop mental health concerns, it is your responsibility to consult with a qualified physician, psychologist, psychiatrist, or other licensed health professional. By participating, you acknowledge and agree that the retreat organizers are not responsible for diagnosing, treating, or managing mental health conditions and are not liable for any mental, emotional, or psychological distress that may arise before, during, or after the retreat. I acknowledge and agree that participation in the above activities involves inherent risks, including but not limited to slips, falls, drowning, heat-related illness, physical strain, emotional discomfort, or other injury. I am voluntarily choosing to participate, and I am responsible for listening to my body and mind and modifying or declining activities when needed. I have disclosed relevant health information and will inform facilitators if changes arise. In consideration of being permitted to participate in this retreat, I hereby release, waive, and discharge: - Lumi Yoga - South Etobicoke Therapy - Carly Bowie (operating as C. Bowie, MSW) - Janet-Lee Song as well as their owners, directors, employees, contractors, volunteers, agents, and representatives from any and all liability, claims, demands, or causes of action whatsoever arising from participation in this retreat, including but not limited to personal injury, illness, property damage, emotional or psychological distress, or loss, whether caused by negligence or otherwise. I consent to receive yoga, meditation, and wellness instruction. In case of emergency, I consent to receive appropriate medical care, with costs being my responsibility. By clicking the checkbox below, I confirm I have read, understood, and agree to the above terms. I agree and understand Thank you!
