Tranquil Retreats - ® OFFICIAL Health & Wellness | Consciousness Expansion

QiGong Classes and Workshops Consent Form

Please complete the pre-assessment intake consent form below. Please fill in as much detail as you can – If you are uncomfortable with any of these questions, feel free to skip them however the more detail you are able to give me about yourself the more I can help you.

Print Full Name

Date of Birth

Occupation

Tel/Mobile contact no:

Previous training history: Martial & Alternative (e.g. Yoga, Meditation, Pilates etc) Please state duration & level achieved:

Please state in full any Medical Conditions or Physical Injuries, past or present, including Mental Health, Surgical Procedures as well as any injections, pills, tablets or medicines prescribed currently by your doctor/pharmacist that may affect your training:

Are you currently being treated by a Doctor? If yes, please details:

Please state in full any Medical condition or physical injury, past or present, including surgical procedures as well as any injections, pills, tablets or medicines prescribed currently by your doctor/pharmacist:

DECLARATION:

I declare that, to the best of my knowledge and belief, the statements made in, or in connection with this Enrolment form are true and complete, and I have not withheld any material facts.

Statement of Consent:

I consent to participating in QI GONG Training. I understand that I can refuse the training at any time and I understand that my personal data will be held in accordance with UK law and with the Tranquil Retreats Data Protection Policy (details can be found on Tranquil Retreats website)

Information shared will not be shared with anyone else without my explicit consent.

We may contact you from time to time with information that may be relevant you.

Please Note: You can unsubscribe from receiving contact from us at ANY TIME by contacting us – info@tranquil-retreats.com or 07984 665 331. For any information about our GDPR compliance policy please contact us.

Date:

Signature:

Disclaimer

I hereby acknowledge that Shi XingFa has no liability, whatsoever, as a result of my participation in QiGong training sessions and that I take full responsibility and liability for any injury, or loss, howsoever caused or sustained, arising directly or indirectly from participating in QiGong training and that all activities undertaken during the said QiGong training sessions are at my sole risk.