Spring Cleanse Registration

Name *

Email *

Cell Phone *

Street Address *

City *

State *

Zip Code *

Emergency Contact (Name & Phone) *

Registering for: *

2021 Ayurvedic Spring Cleanse with Kelley Gardner

What are the top 3 reasons you want to participate in the spring cleanse? *

Are you being treated by a medical professional for any medical conditions? If so, please explain. *

Do you have allergies or an intolerance to small amounts of dairy in the form of ghee (clarified butter)? *

Have you had your gallbladder removed? *

Referred By (List one person, please):

Payment: Date of payment _____________________ *

Zelle – 704-663-9550

Paypal – bit.ly/kelleypaypal (Copy and paste URL)

Venmo – @Kelley-Gardner-7

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