WELCOME! We would like to make your retreat experience with Dagmar Dharma Yoga staff as effective and enjoyable as possible. Please take a few moments to fill out the following intake form. This information will help us understand your needs and ensure your safety and well being during our time together. All information provided will be kept confidential.

Retreat Intake Form Nov 4-11, 2025 Double Accommodation

ROOMMATE INFORMATION - Full Name (as shown on passport): *

(This is for rooming arrangements only. Each participant must fill out a separate form.)

First Name

Last Name

Phone

(###)

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Email *

PARTICIPANT INFORMATION - Full Name (as shown on passport): *

First Name

Last Name

Phone

(###)

###

####

Email *

EMERGENCY CONTACT *

First Name

Last Name

Relationship *

Phone

(###)

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Email *

HEALTH INFORMATION - Do you have any existing medical conditions or allergies the retreat organizers need to know? *

Are you currently taking any medications? If yes, please provide details: *

Are you pregnant? (Select an option)

Do you have any physical limitations or disabilities that may affect your participation in yoga sessions? If yes, please provide details: *

Is there any past injuries or medical issues that may affect your practice?

Do you have any dietary restrictions or food allergies?

What are your biggest desired outcomes from this retreat? For example, are there any specific areas you would like to focus on during the retreat? (e.g. relaxation, flexibility, mindfulness) *

Have you participated in an overseas Yoga Retreat vacation before?

Yes

Have you practiced any of these activities before

Hatha

Gentle Hatha

Restorative

Yin Yoga

Flow

Chair Yoga

Yoga Nidra

Zumba or Similar Dance style

Hiking

Walking

None of the above

Is there any other information you would like us to know or any special request?

I acknowledge that I have provided accurate information to the best of my knowledge. I understand that it is my responsibility to inform the retreat organizers of any changes too my health status or circumstances that may affect my participation.

I have read and accept the Terms & Conditions.

Thank you!

We’ve received your form and appreciate you taking the time to share with us. We’re looking forward to supporting you on this retreat journey and creating a meaningful, safe, and nourishing experience together.

Please note: This is only the initial intake. Additional information may be requested at a later date for airline bookings and travel logistics.

See you soon!

With gratitude,
Dagmar & the DDY Team

Dagmar Dharma Yoga Studio & Boutique

Yoga | Meditation | Reiki | Sound Healing
Wellness for the Active Older Population
“Don’t ever regret growing older, it’s a privilege denied to many…”