2022 Spring Cleanse Registration

Name *

Email *

Cell Phone *

Street Address *

City *

State *

Zip Code *

Emergency Contact (Name & Phone) *

Registering for: 12-Day Ayurveda Spring Cleanse *

March 13-24

March 27-April 7

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? *

Do you have high blood pressure? *

If yes, do you currently take high blood pressure medication?

Referred By (List only one person, please):

To participate in the Spring Cleanse, please fill out the health waiver below. Completed waiver is required for participation in the cleanse. After completing the waiver, navigate back to the cleanse registration form by finding the tab on your internet browser.
Click here to sign the health waiver.

Payment due with registration. *

Zelle – 704-663-9550

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

Venmo – @Kelley-Gardner-7

Have you signed the health waiver? You are not registered until you have signed the 2022 health waiver. Thank you.

Yes