SRI SRI YOGA

REGISTRATION FORM
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Vyakti Vikas Kendra, India, No. 19, 39 A Cross, 11 Main, IV T Block, Jayanagar, Bangalore – 560 041

(Please write clearly and in BLOCK LETTERS. All information in this application will be kept strictly confidential )

Name : _______________________________________ Male [ ] Female [ ]

Home Address : _____________________________________ Married [ ] Unmarried [ ]
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Office Address : ________________________________________________________________
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Phone (Res.) _____________ (Off.) ___________ (Mobile) ___________
Email :_______________________________
Date of Birth : ___________ Educational Qualification : _________________________________
Profession : [ ] Medical [ ] Engineering [ ] Business [ ] Govt. Service – Position _________
Others : Please specify __________________________________________________________

1. Are you experiencing any of the following health conditions ?

Asthma [ ] Epilepsy [ ] High Blood Pressure [ ]
Heart Problem [ ] Back Pain [ ] Pregnancy [ ] Schizophrenia [ ]
Others (Please specify) : _______________________________________

2. Are you currently taking any prescribed medication ?

Yes [ ] No [ ] If yes, please explain ___________________________

3. Have you ever undergone psychiatric treatment before ?

Yes [ ] No [ ] If yes, please explain ____________________________

4. Have you undergone any surgery in the past Yes [ ] No [ ]

If yes, please explain ____________________________________________________

5. How did you come to know about SRI SRI YOGA?

Friends & Relatives [ ] Newspaper Ads / TV [ ] Leaflets / Books / Tapes [ ]

6. Are you repeating this Courses : Yes [ ] No [ ]

If yes, please give the dates when you have attended this program earlier –
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Declaration
I understand that any benefits derived from this course depend upon the extent of my
participation. I therefore, accept full responsibility for the outcome. I willingly agree to follow all
instructions and commit myself to attend all sessions without any exception. I also agree that I will
not disclose the contents of this course to anyone. I declare that I am physically and mentally able
to participate in this programme.

Place : ....................................
Date : Signature

Personal Donation for the Course, Rs. __________

Mode of payment: Cash / DD no. / Electronic Transfer ID ____________ drawn on____________
Bank, dated _______ Electronic transfer id : _______________
Name of the Instructor _____________________