Spring Cleanse Registration 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)? * Select one No Yes Have you had your gallbladder removed? * Select one Yes No 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 If you are human, leave this field blank. Submit